HISTORY Baby PG, a full-term female baby was delivered via NSD  on…

HISTORY

Baby PG, a full-term female baby was delivered via NSD  on 4-20-22 (12:30 PM) with birth weight 3.2 kg at 39th week of gestational age. Baby PG cried soon after birth, No congenital anomalies seen at the time of birth. Vaccination is given. Injection Vit. K 0.1 ml given. Breastfeeding started after 2 hours and the baby was fed every 2-3 hours c/o mother.  At 9:00 am on 4-21-22,the patient’s mother and the nurse noticed that Baby G started to develop mild yellow discoloration in whole body. The mother’s observation was then referred to Dr. Reyes where serum total bilirubin was ordered and  done revealing 13 .2 mg/dl thus phototherapy was ordered.

 

Endorsement: VS q2 especially temperature, For phototherapy with precaution (Started 12pm), Encourage to increase fluid intake/breastfeeding, hook to IV D5 0.3 NaCl at 100ml/kg/day or 13 cc/hr ((hooked at 12:10 pm) at Right basilic vein. For repeat serum total bilirubin after 12 hours.

 

Investigation (Labs): Hemoglobin% – 17.8gm% Blood group- A positive, CRP- Negative Bilirubin level (Before treatment) – Total – 13.2 mg/dl Direct bilirubin- 2.6 mg/dl Indirect bilirubin- 10.6 mg/dl.

 

Anthropometry – 1. Head circumference 33 cm. 2. Chest circumference 31 cm 3. Mid arm circumference (both) 9.5 cm 4. Mid thigh circumference (both) 12 cm 5. Height 49.5 cm 6. Weight 3.2 kg

 

VITAL SIGNS: APRIL 21, 2022

	8AM	10AM	12PM
TEMPERATURE	36.5	37.3	37
RESPIRATORY RATE	34	30	38
HEART RATE	137	140	143
STOOL	–	–	–
URINE		1DC (1.5 oz)	1DC (1 oz)

• Meconium at 1:00 pm

       Phototherapy started 12:00 pM
 

Medication: Iron supplement (Ferlin drops) 0.3cc OD

 

History– Full term female baby (39th week), LSCS delivery, cried immediately after birth, birth weight- 3.2 kg. 

Antenatal History: Age of mother at the time of conception was 22 years and the father was 25 

years. Mother took regular antenatal checkups and took medicine on time, No history of any kind of infections, pregnancy induced hypertension, diabetes, or seizures was reported. 

Blood type: O+ (mother)

 

Postnatal 

Family History: All family member said to be normal. 

 

Immunization History: BCG, OPV, HepB0 

Dietetic History: Exclusive breastfeeding started after 2 hour of birth. 

Personal History: Appetite -Good 

                                Meconium- Passed

                                Micturition -passed 

                                Sleep -Normal
 

General Examination Lung- expanded, Activity- Alert Color- pink 

Apgar score- 1 st min- 8/10 5 th min. 10/10 

 Ballard score- 40 (40th week of gestational age) 

No any congenital anomalies. No any abnormal secretion from umbilical cord
 

CBC:

Hemoglobin- 17.8

RBC- 5

Hematocrit- 54%

WBC-9,000 mm3

Neutrophil-normal

Lymphocytes-normal

Blood type- B+
 

QUESTIONS

1. List the Cephalocaudal (Head to Toe) Assessment and its findings for Normal Newborn.

2. What most likely causes the jaundice in the above case scenario?

 

Explanation & Answer

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