Case presentation

UNIVERSITY OF SOMALIA
Banadir Hospital

Safia ali barre

Personal data
Name:- mahamed liibaan cusmaan
Age: 7 days
Sex: male
Residence: wardhiiglay
Weight: 2.5kg
Height: 50cm
Z-score: > -3
Date of history ;17 0cto 2015

Date

of Admission (DOA): 11-10-

2015
Date of Birth: 10 -10 -2015
Place of Birth: bandir hospital
Informant: His Mother
Hospital: Banadir Hospital

Chief complaints
Convulsion after 8 hours at birth
and
hypothermia

History of present illness

Convulsion
Onset:

suddenly
Duration: 8 hour after birth for right side
then generalized
Associated: with hypothermia
Frequency: convulsion was continuous
within minutes during convulsion baby
conscious was alert not passed urine and
stool
Not known aggravating factors
relieved by anti convulsion drugs

Anti natal history

Health

status of the mother was good

Nutritional status of the mother was
good
During pregnancy has taken
supplemental vitamins for hospital
banadir
Vaccination of the mother for 3 times
for banadir hospital
Monitoring for blood and HB control
was 11.6mg|dl for hospital banadir

-The

mother has no any blood transfusion

-The mother was vaccinated during
pregnancy TT1 and TT2 in banadir
hospital
No radiological performed during
pregnancy.
Medications mother during pregnancy ;
supplemental vitamins

No

obstetrics complications in
past pregnancy
No trauma history
No travels of the mother during
pregnancy
No surgical of the mother during
pregnancy.

NATAL HISTORY
At

birth: he was born full term

(38 weeks)
Delivery by c|s due to the CPD
and prolong labour associated
with week contractions and
undescending fetal head in
banadir hospital
Membrane rupture was 2 days
ago before delivery
Duration of labour 2 days 1day

Post natal history

After

birth:
cry immediately and start with
water
After 8 hours develop for
convulsion and hypothermia
meconium and urine passed after
3 hours
And un able to breast succking

Feeding history
At

the time of delivery start

water untill 5days only water
After 5 days start with
breastfeeding and refuse and
crying as mother reported 6th
day start with SAHA1 and breast
pump for Ngtube
7th days start with breastfeeding
Now for breast feeding

Growth and deve

Weight

;2.5 kg
w|age 5
percentile
Hight; 51cm

h|age 25 percentile
Z score;>-3
HC: 48cm
. Normal range
35---37cm

Family history
Name

of the father: liiban cusman

35 years old . Lives in juba sudan for
business
Name of the mother: qamar huseen
30 years old house wife
The mother has G1 p1+0
Both parents live together and not
relative

There

is no family history of
hypertention diabetic , heart
disease , hypertension both
paternal and maternal side

Socio economic
habits no as the mother reported
living condition normal
Job ;bussines
Economic income; 150 dollar
House hold; 2 rooms for 5 persons 1
room her and her mother
Water source; tap water

Physical examination
Vital signs
RR :50 bpm
according to his age normal range
Temperature: 38.0C
According to his age
Pulse rate :120 beats/min
According to his age its normal
range

General appearance
Patient looks ill fibrile generalised
jaundice no cynosis right hand
iv canula ng tube

Head c;

48 cms round normal

shape smooth hair and black
fontanella not closed

Skin
Generalised jaundice
No skin rash or any lacerations
EYE: jaundice on sclera
No eye disharge no cornea ulceration
NOSE: no nasal suptum abnormality,
normal nasal bridge
MOUTH: no mouth ulceration no ungular
stemotatis angue and mucosa yellow
EAR: no ear discharge no earache

Respiratory system
No chest deformity
On auscultation there is no
wheezing, crackles, and
crepitation. No chest indrowing
Movement with respiration
symitriccal

Cardiovascular system
Normal heart sound
No marmur no tachycardia and
brady cardia

Abdomen
inspection
Abdominal muscles move with
respiration
Umbilicus: not healing
No hernia and vissible veins

palpation
No abdominal mass, and no palple
organs fibrile

Limbs
No cynosis but yellow in nials
and some flexion
Muscles
Muscle

tone are normal.

muscle wested

suspected diagnosis
Neonatal

convulsion
Neonatal jaundice
Neonatal sepsis

Differential diagnosis

breastfeeding jaundice
Hemolytic disease of newborn
Hepatitis
Hpothyrodism
Cytomegalo virus
Cholestasis
Byloric stenosis

Management
Admission icu
Routine delivey care warm and dry
Cord care tetracycline eye ointmen
Vitamin k ij 0.1/kg
Dexstros 10%
Ampicillin injec 1g 100mg*2.5*5/1000mg/3
Gentamycin 80 mg 80mg/2ml diluted
Diazpam for convulsion
Phototherapy
Exchange transfusion

Prognosis
12/10/2015 pt no convulsion urine not passed
NG tube for feeding
13 oct measure blood sugar {3.4} mmol
and 14/ octo urine passed an stool
17/10/pt develop generalised jaundice and
fever urine passed good breast feeding
Plan CBC total biluribin
18 jaudice still present urine passed and stool
passed
Plan pt ptt and breaasst feeding and transfere
hospital digfeer due to exchange transfussion

END

Thank

you