General Information

Fuentes, Baby Boy

DOB: 12/1/15
TOB: 5:17 PM
HPI
The patient is a well-baby born to a 17 yo G1P0 mother via NSD at Ospital ng Makati. AOG
was determined by LMP as 40 1/7 and consistent with UTZ. Rupture of membrane occurred 4
hours prior to delivery and amniotic fluid was clear. The baby was dried, stimulated, and put
on EINC. APGAR scores of 8 and 9.
Maternal History
Fuentes, Danielle Marie Maniego
17 years old, cohabiting, Filipino, Catholic
G1P0
LMP: Feb 22, 2015 (sure)
EDD: Nov 29, 2015
Prenatal Checkup: 8x (3x at OsMak for 3rd trimester, 5x at LHC for 1st and 2nd trimester)
[10/15, 11/5, 11/21]
FIRST TRIMESTER: Learned of pregnancy thru pregnancy test after missing 2 months of
menses. 1st prenatal checkup was done at 3 months AOG at Rizal HC. First UTZ on 6/15/15
revealed single live intrauterine pregnancy, breech in position, 15 weeks AOG by BPD and
FL, posterior fundal placenta grade 0, normohydramnios. Denies exposure to radiation,
history of viral exanthema, and maternal illness. No BP elevation. Regular intake of
multivitamins, folic acid, and ferrous sulfate.
SECOND TRIMESTER. Regular prenatal checkup at Rizal HC. No BP elevation, but was
diagnosed with UTI which was treated with unrecalled antibiotic. Second UTZ on 7/27/15
revealed single live intrauterine pregnancy, breech in position, 26 1/7 weeks AOG by BPD
and FL, posterior high lying placenta grade 1, normohydramnios. Denies exposure to
radiation, history of viral exanthema, and maternal illness. Regular intake of multivitamins,
folic acid, and ferrous Sulfate.
THIRD TRIMESTER
Regular prenatal checkup at Rizal HC. 1st prenatal checkup at OsMak on 10/15/15 showed
good fetal movement, no watery/bloody vaginal discharge, and no uterine contractions. No
BP elevation. Third UTZ on 6/15/15 revealed single live intrauterine pregnancy, cephalic in
position, 31 6/7 weeks AOG by BPD and FL, left posterolateral placenta grade 0,
normohydramnios. Denies exposure to radiation, history of viral exanthema, and maternal
illness. Regular intake of multivitamins, calcium, folic acid and ferrous sulfate.
Past medical:
S/P Appendectomy
No allergy to food and
drugs
Family History:
(+) HPN
Personal/ Social:
Non-smoker
Non-alcoholic beverage
drinker
High school

Unemployed
Lives with partner
With Yellow Card
Menstrual:
Menarche - 11 y/o
Iinterval - regular, 30
days
Duration - 5-6 days
Aamount - 3 pads per
day, moderately soaked
Symptoms - no
dysmenorrhea

Contraceptive use: none

Sexual History:
1st coitus: 15 y/o
Sexual partner/s: 2
1. Student, monogamous
2. Sales staff,
monogamous
No dyspareunia
No postcoital bleeding
(-) Pap Smear

(-) Leukorrhea
Labs:

Blood type A+
HBsAg nonreactive
VDRL nonreactive

75g OGTT FBS 68.4; 1 hr

81.54; 2 hrs 95.94

Physical Examination (1st hour of life)

General: Good activity, good cry, good color, maturity looks grossly appropriate for
gestational age
Skin: No rashes, bruises, petechiae, birthmarks
Head: No deformities
Eyes: No discharge, no cataract
ENT: No cleft lip/palate
Thorax: No retractions, no breast hypertrophy
Lungs: Good air entry
Heart: Normal rate, regular rhythm
Pulses: Full and equal
Abdomen: Umbilical vessels 2 arteries, 1 vein; no organomegally, no masses
Genitalia: Grossly male, no discharge
Trunk and spine: No tufts of hair, no dimpling
Extremities: Full and equal pulses
Anus: Patent anus
APGAR: 8 (1, 2, 1, 2, 2); 9 (1, 2, 2, 2, 2)
Vital Signs: HR 150s, RR 40s, T 37
Anthropometrics: Wt 3.1 kg (p50), Length 51 cm (p90), HC 35 cm (p90), CC 34 cm, AC 32 cm
Maturity Index: 39
Assessment:
Term birth male, AGA
Plan:
1. Admit to EINC unit
2. New born care
a. Vit K 1.0 mg IM
b. Hep B vaccine 0.5 ml IM
c. BCG vaccine 0.05 ml ID at right deltoid before discharge
d. Aseptic cord care with mild soap and water every 6 hours
3. Thermoregulate at 36.3 37.2 C
4. Encourage breast feeding with strict aspiration precaution
5. Allow patient to burp after feeding
6. Monitor vital signs every 15 minutes until stable, every 1 hour thereafter
7. Check O2 saturation at the 24th hour of life
8. For newborn screening at the 24th hour of life
9. For newborn hearing screening care of NET
10. Watch out for fair suck, fair cry, fair activity, temperature instability, cyanosis,
vomiting, seizures, abdominal distention