Aguinaldo, Krista

HISTORY
Informant: Mother

Reliability: 90%
GENERAL DATA
 Patient BM
 12 day old male
 Born on June 12, 2019
 Filipino
 Roman Catholic
 From Penablanca
 1st admission at Cagayan Valley Medical Center
(CVMC) on June 24, 2019 at around 9:00 AM
FEVER

CHIEF COMPLAINT
HISTORY OF PRESENT ILLNESS

 Born to a 35 y/o G2P2 (2002) mother via NSD at a

lying-in in Manila assisted by a Physician BW: 3.1 kg,
BS: 38-39 weeks, AGA.
 Good cry, good suck, pinkish, no cyanosis, no
jaundice and was not in cardiorespiratory distress
 Placed at mother’s bed side
 Discharged without fetomaternal complications
HISTORY OF PRESENT ILLNESS
 Mother recalled to have PNCU 3x at a LHC
 (+) FeSO4, MVS
 (+) fever, cough and colds (2 weeks PTD)
 Paracetamol 500mg/tab taken
 No other co-morbidities

 Cognizant – 2 pregnancy test kit since she had amenorrhea (2

months)
 Prompted consultation at 9th week (CBC, UA, UTZ)
 Assoc sx – weight gain and increase in appetite
HISTORY OF PRESENT ILLNESS
• Fever (38.7 C)
• Decrease in amt and frequency (from 15x to
<10x) of feeding
1 day PTA • No other assoc s/sx such as vomiting or
(11th DOL) diarrhea
• Paracetamol 10mkd given

• Persistence of symptoms despite paracetamol

Few hours intake
th
PTA (12
DOL)
NUTRITIONAL/FEEDING HISTORY

– Presently breastfed (20-30mins) per demand (15x)

– No noted reactions to breast milk
– BM 3-5x/day
– Urine output (diaper change >5x)
– AA, MVS given
IMMUNIZATION HISTORY
Vaccine Dose/s
BCG 1

Hepa B 1

Pentavalent 0
(DPT,OPV,Hib)
MMR 0
PCV 0
FAMILY HISTORY
 Youngest in a brood of 2

 FATHER, 38, unemployed

– No known illness
– No history of heredo-familial diseases noted
 MOTHER, 35, beautician
– No known illness
– No history of heredo-familial diseases noted
PERSONAL & SOCIAL HISTORY

 Cemented, bungalow-type house, well lit, with

adequate space and ventilation, with pets

 (+) recent contact with a sick person

Review of Systems
 REVIEW OF SYSTEMS

Integumentary Head Gastrointestinal

Cardiac Respiratory
(-) Lesions (-) lacrimation (-) Loose bowel movement
(-) cyanosis (-)Dyspnea
(-) Pigmentation (-) aural discharge (-) Bloody stool
(-)cough
(-) Pallor (-) nasal discharge (-) Passage of worms
(-)colds
(-) Jaundice (-) epistaxis (-)Vomiting
(-ta
(-) salivation
Musculoskeletal
Genitourinary (-) swelling in bone
CNS (-) limitation of motion
(-) change in color of urine
(-) Change in behavior (-) stiffness
(-) Oliguria
(-) Seizures (-) limping
(-) Hematuria
(-) weakness
PHYSICAL EXAMINATION
• GENERAL APPEARNCE

Patient is seen lying on the hospital bed, awake,

weak-looking, and in cardiorespiratory distress.
 VITAL SIGNS
TEMPERATURE 38.2 C (axillary)
HEART RATE 158 bpm
RESPIRATORY RATE 56 cpm
ANTHROPOMETRIC MEASUREMENTS
3.18 kg
WEIGHT
HEIGHT 51 cm
BMI 11
HEAD CIRCUMFERENCE 33 cm
CHEST CIRCUMFERENCE 33 cm
ABDOMINAL CIRCUMFERENCE 32 cm
Wt: 3.18 kg GA: 38-39 BL: 50cm
weeks

HC: 33 cm
 I: (-) Jaundice, pallor, cyanosis, rashes, desquamation
SKIN pinkish color
P: Warm to touch

I: Normocephalic, no lesions
HEAD
P: Open fontanels, non bulging

I: (-) Redness
(-) Icteric
EYES Equally Round, both reactive to light
and accommodation
Pink palpebral conjunctiva
 I: Normal-shaped pinna
EARS P: (-) lesions, mass
firm, instant recoil

I: Midline septum
NOSE (-) Lesions
(-) alar flaring

I: Uvula and Tongue midline

THROAT & MOUTH
P: No cleft palate

I: Midline
NECK
P: (-) Palpable lymph nodes
 I: Symmetrical
(-) Retractions, no clavicular fractures
CHEST and LUNGS
P: Symmetrical Chest Expansion
A: (-) Rales, Crackles

P: Adynamic precordium
CARDIO-VASCULAR A: Point of Maximal Impulse (PMI) on 4th ICS-MCL
Tachycardic, Regular Rhythm

I: Round, globular
(-) Scars, lesions
Umbilical cord (2 arteries, 1 vein)
Patent anus
ABDOMEN
A: Bowel sounds every 10 sec (normoactive)
P: Tympanitic
P: Soft, (-) masses
GENITO-URINARY I: (-) grossly male, testes, 2 descended

I: Symmetrical Extremities
MUSCULOSKELETAL SYSTEM no deformities, no club foot
spine straight and midline

I: Pink nail beds

PERIPHERAL VASCULAR
SYSTEM (-) edema, clubbing of nails
P: Full and equal pulses (CRT <2s)
NEUROLOGIC
Mental Status: Patient is awake, weak-looking
Cranial Nerves: Intact

CN:
II – Pupil equally round Primitive Reflexes Result
and reactive to light Moro reflex (+)
V – cries and frowns Rooting reflex (+)
VII – symmetrical face
Palmar grasp reflex (+)
IX, X – able to swallow
XI – can move head side to Plantar grasp reflex (+)

side Tonic neck reflex (+)

XII – no tongue deviation Babinski reflex (+)
Salient features
12 day old, male
Fever (38.7)
Decrease in appetite
Tachypnea, tachycardia
Maternal hx (+) fever, cough/colds (2 wks PTD)
CLINICAL IMPRESSION
 Live baby boy full term at 38-39 weeks by BS, delivered
via NSD to an 35 y/o G2P2(2002) mother BW: 3.1kg, AGA
 Sepsis neonatorum, late onset
Take - off point
 Differential diagnosis

Neonatal pneumonia

Rule in Rule out

Fever Alar flaring
History of maternal illness Grunting
Tachypnea Retractions
 Differential diagnosis

Neonatal meningitis
Infection of the meninges and CNS in the first month of life

Rule in Rule out

Fever Seizure
History of maternal illness Bulging fontanels
Vomiting
COURSE IN THE WARD
 Day of Admission
Problems Assessment Intervention
T: 38°C Sepsis neonatorum, BF with SAP

CR: 148bpm late onset Heplock

RR: 56cpm Medications
• (200) Ampicillin 170
O2 sat: 98% • (5) Gentamycin 17
Weight: 3.18kgs • (10) Paracetamol 35
• Credes prophylaxis
• Vit K 1 mg/IM
• Hep B 0.5 ml/ IM
• BCG 0.05 ml/ID

Diagnostics:
• CBC, Blood CS, BT
• Urinalysis
• CXR AP/Lat
• Hearing Screening test

Daily baby bath

Keep thermoregulated
VS q 2
I and O q shift
WOF untoward s/sx
refer
 Complete Blood Count Reference Range

Hemoglobin 117 150-240

Hematocrit 0.34 0.44- 0.70
Platelet count 757 84- 478
WBC 14.0 9.1- 34
Neutrophils 33.5 54- 62
Lymphocytes 49.6 43-53
• JUNE 24, 2019 (25)

Blood CS
• Positive for staphylococcus intermedius after
18 hours of incubation
• (gentamicin S 26mm)
 Day 1 of hospitalization
Problems Assessment Intervention
CR: 143 Sepsis neonatorum, late •BF c SAP
PR: 53 onset •Meds: ampicillin,
T: 38.2 gentamycin, paracetamol
•Hep B, BCG given

DAY 2
Problems Assessment Intervention
CR: 145 Sepsis neonatorum, late •BF w/ SAP
PR: 47 onset •Continue meds and mgmt.
T: 36.6 •hearing screening done
 Day 3
Problem Assessment Intervention
•Maintain heplock
•Cont. meds and mngt.

DAY 4
Problem Assessment Intervention
•Cont. meds and mngt.
•Vit K given
•CBC

Complete Blood Count Reference Range

Hemoglobin 108 150-240

Hematocrit 0.31 0.44-0.70

Platelet count 666 84-478

WBC 12.9 9.1-34

Neutrophils 28.4 54-62

Lymphocytes 50.7 43-53

DAY 5
Intervention
•Continue meds and mgnt.

Day 6
Intervention
•Continue meds and mgnt.
 DAY 7
Problems Assessment Intervention
•BF w/ SAP
•Continue meds and mngt.
•Dx: CBC

Complete Blood Count Reference Range

Hemoglobin 187 150-240
Hematocrit 0.48 0.44-0.70
Platelet count 553 84-478
WBC 18.7 9.1-34
Neutrophils 24 54-62
Lymphocytes 52 43-53
Day 8
Intervention
•MGH
•Home meds:
MVS .3 ml OD
AA .3 ml OD
 definition

Neonatal sepsis
• a clinical syndrome of systemic illness accompanied
by bacteremia ocurring in the first month of life
 incidence

• 1-8 per 1,000 live births

• 13-27 per 1,000 for infants weighing < 1,500
g
• Higher rates in premature infants and in
those with early fulminant disease
 pathophysiology

A. Early-onset disease
• First 5-7 days of life
• Usually a multisystemic fulminant illness with
prominent respiratory symptoms
• Associated with acquisition of microorganisms from
the mother
 pathophysiology

B. Late-onset disease
• As early as 5 days of age
• More common after the 1st week of life
• Usually have an identifiable focus, most often
meningitis in addition to sepsis
• Acquired from caregiving environment
 CAUSATIVE AGENTS
• Group B streptococci (GBS)- most common
• E. coli
• Lysteria monocytogenes
• Staphylococcus
• Streptococcus
• Anaerobes
• H. influenzae
 Risk factors
• Prematurity and low birth weight
• Rupture of membranes (>18h)
• Maternal peripartum fever( ≥ 38°C) or infection
• Amniotic fluid problems
• Resuscitation at birth
• Multiple gestation
• Invasive procedures
• Infants with galactosemia
• Iron therapy
 Clinical presentation

• Temperature irregularity
• Change in behavior
• Skin
• Feeding problems
• Cardiopulmonary
• Metabolic
 diagnostics
Laboratory studies
• Cultures
blood - Gold standard for bacteremia
1-2ml / sample – optimal amount
• Gram’s stain
• CBC
• Acute phase reactants
• Miscellaneous tests
 diagnostics

Radiologic studies
• Chest x-ray film
• Urinary tract imaging
Complications and supportive therapy
• Respiratory
ensure adequate oxygenation
• Cardiovascular
support blood pressure and perfusion

• Hematologic
DIC- treating underlying disease
Neutropenia
• CNS
implement seizure control measures and monitor
SIADH
• Metabolic
monitor and treat hypo- or hyperglycemia and metabolic
acidosis
 prognosis

• Mortality rate: 12-25%

• Extremely LBW infants have significantly
greater risk of poor neurodevelopmental
outcome
 SUMMARY
Neonatal sepsis
• a clinical syndrome of systemic illness accompanied by
bacteremia occurring in the first month of life
• 1-8 per 1,000 live births
• Mortality rate: 12-25%
A. Early-onset disease
B. Late-onset disease
• Prematurity- single most significant factor correlated with sepsis
• Group B streptococci (GBS)- most common causative agent
• Culture blood - Gold standard for bacteremia
• Empiric therapy: ampicillin and gentamycin
THANK YOU