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CHAPTER II

CLIENT PRESENTATION

This is the case of Baby Boy B. of R.F. a live full term delivered via repeat

Caesarean Section on September 16, 2009 at 0751H in a tertiary hospital in Makati City.

The patient is 37 weeks AOG (Age of Gestation) by LMP (Last Menstrual Period) and 39

weeks by MI (Maturity Index), AGA (Appropriate for Gestational Age).

The patient is born to a 29 year old mother, G2P1, with a TPAL score of 1-0-0-

1.Last 2008, she delivered a full term baby girl delivered via caesarean section with no

problems encountered. The patient's mother started having regular prenatal check ups

since third week of first month, regular medications include multivitamins (B complex),

iron for enhanced oxygenation, folic acid, and calcium for supplying the nutrients of the

baby as well as the mother

The mother had experienced vaginal bleeding during the 5th week f age of

gestation and OB’s impression was threatened abortion. She had URTI (Upper

Respiratory Tract infection) during her 4th month of age of gestation and did not take any

medications. On the other hand, throughout the pregnancy, she had episodes of elevated

blood pressure and blood sugar. The mother did not have any exposure to radiation,

teratogenic drugs and viral exanthems. Family history includes congenital anomalies

(cleft palate) on the paternal side, diabetes mellitus on the maternal side, hypertension

and asthma on both sides.


On September 16, 2008, at 0751H Mrs. R.F. gave birth though elective caesarean

section with clear amniotic fluid under spinal anesthesia. Baby B had good color, tone,

and activity. Baby B.’s nose, mouth, throat secretions was suctioned, placed under radiant

warmer for thermoregulation, place on O2 with mask with 1 cord coil around the neck,

stimulated and cried spontaneously. He was then dried and cleaned. The patient was

given an APGAR score of 9 for the first minute and still the same after 9 minutes.

At 0800H Baby B. was then transferred and admitted at the Nursery Department.

After admission, the patient was then weighed and anthropometric measurements were

taken and revealed the following results: Birth weight: 3147 grams (6 lbs 15 oz), Birth

length: 49 cm, Head circumference: 35 cm, Chest circumference: 33.5 cm, Abdominal

circumference: 29.5 cm, and Biparietal diameter: 8.6 cm. After taking the anthropometric

measurements, routine newborn admission care follows which includes placing the

patient under the radiant warmer, initial suctioning, gastric lavage, administration of 1mg

IM x 1 dose Vitamin K , 0.5cc IM Hepatitis B vaccine on the left anterolateral thigh, eye

prophylaxis (Terramycin), initial bathing, and cord dressing.

The patient's initial vital signs were also taken and revealed the following: Baby

B. is tachypneic with a range of 70-80 breaths per minute. Initial physical examination of

the patient revealed the following: (-) jaundice, (-) lesion, (-) caput, (-) cephalhematoma,

(-) eyes, ears, nose discharges, (-) cleft lip, (-) cleft palate, (-) tongue tie, symmetrical

chest expansion, clear breath sounds, (-) murmurs, (+) patent anus, (-) deformities and the

umbilical cord was noted to have two arteries and one vein.
At 1000H-1040H, patient was showed and latched to the mother. At 1450H the

doctor visited patient and ordered for a chest x-ray and complete blood count and blood

typing. Hyperaerated lungs was the result for chest x-ray, elevated Hemoglobin with

24.40g/dl (normal range- 13.5- 22.5), elevated Hematocrit with 69.90% (normal range –

42-67), elevated WBC with 37.00 x 10^3/ul (normal range – 9–34), decreased

lymphocytes with 18.00% (normal range – 21-36) , elevated RDW in the platelet count

has 16.00% (normal range – 11.60-14.60) were the result for the CBC test and negative

(quatlitative) in CRP test. Baby B. has a Blood type O+. The doctor ordered the patient

for NPO.

At 1530H, the researchers received the patient asleep in the radiant warmer in a

supine position, with ID band on the right hand and on the right leg. The patient’s

temperature was checked again and revealed the temperature of 36.7ºC. heart rate of 123

beats per minute and respiratory rate of 75 cycles per minute. Baby B. was closely

monitored and vital signs were taken every hour.

At 1800H, the doctor ordered for a repeat complete blood count and results

revealed that Hemoglobin, hematocrit and white blood cells were already in the normal

range. Lymphocytes were still low with 16.00% (normal range – 21-36) and an elevated

RDW of 15.50% (normal range – 11.60-14.60) At 1900H, Baby B. was hooked to O2 at

1 lpm via nasal cannula, and orogastric tube was placed. Baby B was placed on a prone

position. Patient’s vital signs taken for 2100H: temperature-36.6°C, heart rate – 113 beats

per minute and respiratory rate – 68 cycles per minute. At 2015H, patient was infused

with 50cc of D10water at 10.5ml/hr on the right hand and random blood sugar should be

done 1° after IVF was hooked. .At 2100H, Cefotaxime 175mg Q12H for 100mg/kg/day
and Amikacin 47mg Q24H for 15mg/kg/day were administered via IV push by the nurse

with the doctor’s order. Random blood sugar was done with a result of 92 mg/dl.

At 2200H, patient was endorsed for the night shift asleep, tachypneic with a

respiratory rate of 79 breaths per minute, NPO until eupneic, still hooked with IVF

D10W at 10.5ml/hr on the right hand with an output: urine - 8 gms. and stool – 1x

meconium and moderate and a 104 mg/dl result of latest random blood sugar. Newborn

screening was still on hold.

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