Clerk Marienelle Maulion
Vomiting
M. S.
4 month old
Female
Filipino
Santolan, Malabon
2 DAYS PTC 1 episode of vomiting, nonbilious,
projectile, bloodtinged, approx. ¼ cup
No difficulty of breathing, no cough, no
fever, no diarrhea, no abdominal
enlargement
No consult was done
1 episode of vomiting, nonbilious,
1 DAY PTC projectile, bloodtinged, approx. ¼ cup 30
minutes after feeding
FEW HOURS
Defecated a dark green meconiumlike stool
in minimal amount
PTC
Hence, consult was done
No weight loss, no loss of appetite
No jaundice, no rashes, no pallor
No easy fatigability
No change in color in urine
No easy bruising, no bleeding
No seizure, no convulsion
GESTATIONAL HISTORY
Maternal Age: 35 years old
OB Score: G1P1 (1001)
Regular Prenatal Check ups
Ascorbic acid, FeSO4, Isoxsuprine
DM Screening: Negative
Hepa B Screening: unrecalled
Illness: UTI
No alcohol intake, no smoking, no X ray exposure
Given Betamethasone injection prior to delivery
BIRTH AND NEONATAL HISTORY
Manner of delivery: CS under Spinal
anesthesia
Indication: Placenta previa totalis
Gestational Age: 34 to 35 weeks
APGAR Score: 5, 7, 9
Resuscitation: Ambubagging
Complication: Depressed Baby
Newborn Screening: Negative
Head control: 2 months
Grasps rattle: 3 months
Social Smile: 3 months
Gross Motor: Good head control, Strong
grasp, Good flexion
Fine Motor: Holds/Pulls an object
Language: Turns toward a sound or when
called by mother or caregiver
Social: Smiles, chuckles
Breastfed 8x/day for 10 minutes each breast
until 3 months
Milk formula: Enfalac A+, 7 oz each feeding 6
8x/day
BCG: 10/6/2010
Hepa B: 110/6/2010; 211/23/2010
DTP: 111/23/2010; 212/31/2010; 31/30/11
HiB: 112/31/2010; 21/30/2011
OPV: 111/23/2010; 212/31/2010; 3
1/30/2010
Pneumococcal Vaccine: 1/16/2011
At Birth
◦ Sepsis, Clinical, Neonatal Pneumonia
◦ Ampicillin, Gentamycin
◦ Hospitalized for 4 days
3 months
◦ URTI
◦ Clarithromycin, Ambroxol
◦ Amoebiasis
◦ Metronidazole
Father: 35 years old, College graduate, in
good health status
Mother: 35 years old, College graduate, bank
employee, in good health status
Hypertension and Heart Disease
◦ Grandmother
Primary Caregiver: Grandmother, ES, 72 y.o.
Single parent: Mother, MS, 35 y.o.
Renting/Living in a concrete bungalow
apartment
Average monthly income: 20,000
Water source for consumption: Distilled water
(Wilkin’s)
Garbage: Segregated, collected once a week
Exposed to: Cigarette smoke and Animal pets
of neighbors
Alert, Conscious, not in Cardiorespiratory distress
Well looking, well hydrated, well nourished
CR: 124bpm, RR: 32cpm, T: 36 8°
Length: 63cm (Z: 0), Weight: 6 25kgs (Z below 1), HC: 41cm, CC:
41cm, AC: 41cm
Skin: ()pallor, ()jaundice, good skin turgor
Head: Normocephalic, atraumatic
Eyes: Pink palpebral conjunctivae, anicteric sclerae, pupils 34mm
ERTL
Ears: No tragal tenderness, nonhyperemic & patent EAC, AU, intact
TM, AU, retained cerumen
Nose: Midline septum, turbinates not congested, no nasal
discharge
Moist buccal mucosa, nonhyperemic
pharyngeal wall, tonsils Grade 2
Supple neck, no palpable cervical lymph nodes
Symmetric chest expansion, no alar flaring, no
retractions, normal breath sounds
Adynamic precordium, AB 4th LICS MCL, no
murmur
Globular abdomen, NABS, Soft, Nontender, no
masses
Grossly normal extremities, pulses full & equal
Essentially normal
t/c Cow’s Milk Allergy
Supportive
◦ Shift milk formula to hypoallergenic milk formula
◦ Continue multivitamins
Prophylactic
◦ Burp midway and after each feeding
◦ Elevate head of at least 30° for at least 30
minutes after feeding
Preventive Health Care/Anticipatory
Guidelines
◦ Watch out for persistent vomiting, abdominal
distention, loose stools