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RT8-PEDS H&P

RT8- Pediatrics H&P3 (Pediatrics ED)

Jinjin Lin

 

Identification:

Patient’s name: M.C

DOB: 3 days old

Gender: female

Race: Hispanic

Location: Queens hospital center, pediatric ER

Date and Time: 10/25/2019, 3pm

Informant: patient’s mother, reliable

CC: “baby’s skin is more yellow” X 2 days

HPI: A 3 days old female infant born at 40 weeks gestation via normal spontaneous vaginal delivery without complications, brought to pediatrics ED by mother with a complaint of yellowing of skin x 2 days. Mother stated that the patient was discharged from newborn service/QHC yesterday with an elevated bilirubin level and she was instructed to bring the baby to ED if there are any concerns. Mother reported that the patient has more yellow skin than yesterday, otherwise, baby is doing well, tolerates feeds with breast feed, voiding and had several greenish color stools.

PMH:

The patient was born to a G2P2 Hispanic mother with blood type O+ with normal screening maternal laboratories and no eventful pregnancy

APGARS: 9 in one min and 9 in 5 min

Birth weight 3248 grams, birth length 50cm, head circumference 32cm, chest 32cm, abdomen 31cm

Past Surgical History:

Denies any past surgical history.

Medications:

Denies taking any medications.

Allergies:

Denies any drug, foods, or environment allergies.

Family History:

Father, alive and well

Mother, alive and well

Social History:

M.C is 3 days old baby, lives with his parents in Jamaica, NY.

ROS:

General: Denies fever, chills, loss of appetite, recent weight loss or weight gain, generalized weakness, or night sweats

Skin, Hair, Nails: report jaundice, denies any changes of texture, moles, rashes, or pruritus

Head: denies headache, or head trauma

Eyes: denies visual disturbance, lacrimation, photophobia, pruritus

Ears: denies deafness, pain, discharge, tinnitus

Nose/Sinuses: denies discharge, epistaxis, or obstruction

Mouth and throat: denies bleeding gums, or sore throat

Neck: denies localized swelling or lumps, or stiffness

Breast: denies lumps, nipple discharge, pain

Pulmonary System: denies SOB, DOE, cough, wheezing, or cyanosis

Cardiovascular System: denies chest pain, palpitations, syncope, or known heart murmur

Gastrointestinal System: reports jaundice, denies abdominal pain, vomiting, diarrhea, dysphagia, constipation, rectal bleeding, blood in stool

Genitourinary System: denies changes in frequency, nocturia, polyuria, dysuria, dribbling

Nervous System: denies seizures, headache, loss of consciousness, numbness

Musculoskeletal System: denies muscle and joint pain, denies deformity

Peripheral System: patient denies intermittent claudication, peripheral edema

Hematological System: denies anemia, easy bruising or bleeding, or lymph node enlargement

Endocrine System: denies polyuria, polydipsia, polyphagia, heat or cold intolerance or goiter

Physical Examination:

General: 3 years old female infant is alert and active, well-appearing with good cry, easily consoled, in no acute distress

Vital Signs:

BP (seated): 77/47

HR: 139 BMP

RR: 32

Temp: 98.4 F rectal

O2 sat: 99% room air

Weight: 3402 grams

Skin: Warm & dry, capillary refill less than 3 seconds. Jaundice noted, no lesions, no scars, no rash, no cyanosis

Hair: Average quantity and distribution

Head: Anterior fontanelle is flat, no cranial deformity or facial anomaly, non-tender to palpation throughout

Eyes: Symmetrical OU; sclera white; conjunctiva & cornea clear. Pupils equal round and reactive to light

Ears: Symmetrical and normal size, well positioned, well-formed pinnae. No discharge, foreign bodies in external auditory canals AU

Nose: Symmetrical with no masses, lesions, deformities, or trauma. Nasal mucosa pink, no discharge or foreign bodies

Mouth/Throat: Lips pink, moist, no cyanosis; mucosa light pink, no masses, lesions, or leukoplakia; tongue pink; oropharynx hydrated and clear

Neck: No masses, lesions or scars. Supple nontender to palpation

Chest: Symmetrical, no deformities, no trauma. Respirations unlabored. Nontender to palpation

Lungs: Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. No wheezing, crackles, rales, tachypnea or retractions

Heart: S1, S2 without murmur, no gallops, S3 or S4. RRR

Abdomen: Flat and soft. Bowel sounds in all 4 quadrants. No distension, nontender to palpation, no rebound tenderness or guarding. Umbilical cord clamped and dry, no signs of inflammation

Female genitalia: anus appears patent, no rash

Neurological: Easily aroused, good symmetric tone and strength, normal newborn reflexes, symmetric moro reflex, normal root and suck

Musculoskeletal System: Ortolani’s and Barlow’s signs absent bilaterally, leg length symmetrical and thigh and gluteal folds symmetrical. No soft tissue swelling, erythema. Nontender to palpation. Good tone for gestation. Full range of motion of all upper and lower extremities bilaterally

 

Differential diagnosis:

  • Breast feeding jaundice
  • Breast milk jaundice
  • Physiologic jaundice
  • Reabsorption of extravascular blood
  • Hemolytic anemia (G6PD deficiency/Hereditary spherocytosis)
  • Polycythemia
  • ABO incapability
  • Rh incompatibility
  • Hirschsprung disease
  • Pyloric stenosis
  • Crigler-Najjar syndrome
  • Gilbert syndrome
  • Hypothyroidism
  • Hepatitis
  • Dubin-Johnson syndrome
  • Metabolic disorders (Alpha-1 antitrypsin deficiency/cystic fibrosis)
  • Bile plug syndrome/cholestasis

 

Laboratory:

  Ref range 10/24/19 10/25/19
Total bilirubin 0.0-8.0 mg/dL 12.2 13.0
Direct bilirubin 0.0-0.3 mg/dL 0.3 0.3
Indirect bilirubin 0.2-1.0 mg/dL 11.9 12.7

 

Mother O+, baby O+, coombs negative

Assessment: A 3 days old female infant full term, via normal spontaneous vaginal delivery without complications, brought to pediatrics ED by mother for yellowing of skin x 2 days. Physical examination notable for skin jaundice. Labs noted total bili 13.0 and indirect bili 12.7. Current findings most consistent with physiological jaundice.

Plan:

  • Physiological jaundice:
  • NICU attending consulted by phone, recommended to repeated bili level on Sunday, if still elevated, admit to NICU
  • Phototherapy scheduled
  • Continue breast feeding, expose baby to sunlight
  • Reassurance
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