Admission RoundExt. จริ�ยาภริณ์� พัฒนกุ�ลเล�ศExt. สาธิ�ญา ริตนส�นทวี�ส�ข

General Data

• ทาริกุแริกุเกุ�ดชายไทย• Date of Birth – 9 พั.ค. 2557, 3.39 น.• Age - 39 minutes after birth (4.15 น.)• ภ�มิ�ล!าเนา จ.เช�ยงริาย• CC: Tachypnea (RR 70/min)

Maternal History

• Mother was 32 y/o• G2P1A1L1• Monthly ANC 7 times at

another hospital– 1st ANC was GA 9+5, 12th

Nov 2013

• Anti-HIV: NR; HBsAg: Neg; VDRL: NR

• Blood type= O Rh +• No fever

• No intrapartum conditions, illnesses, or underlying diseases during pregnancy

• No history of smoking, alcohol, illicit drugs or any medication

Natal History

• Preterm (35 weeks)• C/S due to primibreech• PPROM of 4 hours• BW=2,200 gms (AGA)• APGAR=9,10,10• No resuscitation

Neonatal History

• ริบใหมิ&จากุ LR มิาด'วีย shallow and rapid breathing at 70/min, irregular, with nasal flaring and mild retraction

• suction เสมิหะขาวีข�&นมิ�จ!านวีนมิากุ O2 Sat=98%• No cyanosis, asphyxia, thick meconium, or

fever noted• Admitted at 39 minutes old (4:15 AM)

Family History

• No known heredofamilial diseases• No exposure to smoking in the family

Physical Examination

V/S• T=37.2°C• PR=137/min,

regular• RR=74/min• SpO2 94%• BP=63/39

mmHg

Anthropometry• BW=2,200

gms• Lt=46 cm• HC=33 cm• CC=28 cm

GA• Active• No

dysmorphic feature

• Dyspneic with nasal flaring

Physical Examination

Skin• No pallor, no

jaundice, no cyanosis, no plethora

• No purpura

HEENT• Fontanelles not

depressed or bulging

• No mass or swollen scalp

• No cleft lip/palate

• No ear or nasal secretion

Chest/ Lungs• Symmetrical, no

lesions, (+) mild retractions, no lags

• Tachypnea• Equal breath

sounds• No stridor, no

crepitation, no wheezes/rhonchi

Physical Examination

Heart• No visible

hyperactive precordium

• Normal rate, regular rhythm

• Normal S1 S2• No murmur• No distant heart

sounds• No thrills

Abdomen• Globular, no

distention, no lesions

• Normoactive bowel sounds

• Soft, no tenderness, no spleen or liver enlargement

Genitalia• Normal male

genitalia

Physical Examination

Anus• Patent

Extremities• Warm pink• No gross

deformities• No clubbing• No edema• No collapsing

pulses

Neuro• Alert• No stiff neck• Normal grasping

reflex• Babinski positive

Problem List

• PPROM of 4 hrs• Preterm (35 weeks)• Respiratory Distress soon after birth

– Dyspnea– Tachypnea (70/min)– Nasal flaring– Mild retraction

Differential Diagnoses(Respiratory Distress)

Pulmonary Conditions

• TTN (Wet lung syndrome)

• RDS/HMD• Congenital Pneumonia• Meconium aspiration

syndrome• Perinatal asphyxia

Extrapulmonary Conditions

• Sepsis• Pneumothorax• Hypoglycemia• Polycythemia• Cold stress• Hypothermia

Extra Notes (Hidden Slide): RD that can be ruled out initially

MAS: no history of mconium stained

Pneumothorax: no history of fetal distress, resuscitation, difficult

delivery, aspiration of meconium, blood, or mucus; in PE findings: (-) cyanosis, symmetrical chest wall on

expansion, equal breath sounds, liver not palpable, and no distant

heart sounds

Perinatal asphyxia: APGAR 9,10,10 with

no history of fetal distress, resuscitation, or meconium stained

Cardiac conditions (heart failure or PDA): no murmur, collapsing pulses, cyanosis, or

hepatomegaly

Cold stress or hypothermia: no history of low or

unstable temp recorded within 39 minutes of life

Pulmonary ConditionsDifferential diagnosis

PROS CONS Investigation

Transient Tachypnea of Newborn

• Preterm• C/S• RD soon after birth

- CXR

Respiratory Distress Syndrome / Hyaline Membrane Disease

• Preterm• RD soon after birth

• Active• No cyanosis• No edema

CXR

Congenital Pneumonia

• Preterm• PROM• RD soon after birth

• No maternal/NB fever• No records of predisposing factors: (no chorioamnionitis, no offensive liquor at birth)• PROM < 18 hours

CBCHemocultureCXR

Extrapulmonary ConditionsDifferential diagnosis

PROS CONS Investigation

Sepsis • RD• Preterm• PROM

• Active with APGAR 9,10,10

• PROM <18 hrs• no maternal/NB fever• Other SIRS criteria not

met

• CBC• H/C• UA• CRP

Hypoglycemia • RD• Preterm

• Active• No maternal DM

DTX

Congenital Anomalies

RD • No pertinent PE findings

CXR

Polycythemia / Anemia

RD • No plethora / pallor• Active

CBC

Laboratory Investigation9/5/57• CBC

– Corrected WBC=12,210uL; Neutrophils 43%, Lymphocytes 53%, Eosinophils 4%

– Hb=14.5 g/dL; Hct=43.4%– Platelet count = 398,000 uL

• CXR = no infiltrate, air bronchogram, haziness, mediastinal shift, cardiomegaly or anomalies

• DTX=81 mg%

11/5/57• CRP < 5.0 mg/L• H/C = No growth

After investigations, the ff may be ruled out:

CBC:•Congenital Pneumonia (confirmed again with CXR)•Sepsis (other 3 criteria of SIRS are not met: Temp, HR, WBC; confirmed again with CRP and H/C)•Polycythemia•Anemia

CXR:•RDS•Congenital Pneumonia (agreed with CBC)•Congenital Anomalies•MAS•Pneumothorax•Heart Failure

DTX:

•Hypoglycemia

CRP & H/C

•agreed with CBC for Sepsis

Transient Tachypnea of NewbornImpression:

Management Plan

One-day Orders• NPO (due to RD to

prevent aspiration)• Start IV fluid

– 10% D/W 500ml IV 5.9 cc/hr

• On O2 box 5LPM• Keep O2 sat ≥92%• Vitamin K 1mg IM• Supportive care

Continuous Orders• Antibiotics 5 days

– Ampicillin 220 mg IV q 12 hr– Gentamicin 8.5 mg IV OD– Couldn’t rule out Early Onset

Sepsis on admission, hence give Ampicillin (100 mkdose) + Gentamicin (4 mkdose)

• Routine newborn care, record V/S q 4 hours (SBP, Temp, RR, HR, SaO2), record BW OD, record Lt & HC once a week

Progress Notes

Thank You