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