Baby boy A., preterm, 36 weeks by Ballards score was delivered by Ceasarian section at a private hospital to a 32 year old multigravid with Apgar score 8 and 9 at one and five minutes, respectively. Birth weight was 2.3kg. Birth length 45 cm.
Mother, on the 3rd trimester, had urinary tract infection treated with Amoxycillin 500mg/cap, 1 capsule TID for 1 week. Thereafter she was admitted in a private hospital due to preterm labor where tocolysis was done. Two days prior to delivery, the mother had persistent watery vaginal discharge. She was admitted at a private hospital. Pelvic ultrasound done showed Pregnancy uterine 36 weeks.
Upon delivery, the patient had good cry and activity. On physical examination, patient had features compatible with 36 weeks Ballard’s score. CR 150/min RR 40-50/min T 36.5. He had symmetrical chest expansion with good air entry. No rales noted. Abdomen was soft and globular. Liver was palpable 2 cm below right subcostal margin. No cardiac murmur. Peripheral pulses were good. Capillary refill time was 2 seconds. Neurological examination was essentially normal.
The patient was roomed in with the mother after routine newborn care. He was breastfed per demand. At 6 hours of life, he was observed to have tachypnea at 90/minute with episodes of cyanosis, alar flare, and intercostal retractions.
Family lives in a one-storey shanty along the riverbank of Marikina City, sharing the abode with the maternal side (grandparents). Father works in a shoe factory in Marikina City, earning minimum wage. Grandparents foot the house bills (utilities).
1. Identify from the story the pertinent historical information that will lead you to a clinical impression and differential diagnoses 2. Interpret the pertinent historical data and craft the history of present illness . 3. Identify the pertinent objective data or physical findings from the case that will confirm and support the clinical history and may lead you to a clinical impression and differential diagnoses. 4. Discuss the stakeholder analysis that may modify (adversely or otherwise) management of this case from the perspective of work-up and principles of intervention.
Family lives in a one-storey shanty along the riverbank of Marikina City, sharing the abode with the maternal side (grandparents). Father works in a shoe factory in Marikina City, earning minimum wage, which is php419. Grandparents foot the house bills (utilities). The financers of the patient are his father and grandparents. The baby is pre-term at 36 weeks, also has low birth weight 2.3kg (normal is 2.53kg for Filipino babies). The baby is currently experiencing respiratory distress, and if there are medicines, procedures that are needed, the family’s patient may not be able to afford it and the patient’s condition may further aggravate. As mentioned, the patient’s family lives in a shanty which may cause infection to the baby. the doctor should educate the patient’s mother, and family on the patient’s situation for them to have an educated decision, on the different procedures, medicines and simple to help them raise the patient healthy, and free from infections and other diseases.
5. Present a summary of the salient features of the case, both the clinical history and physical attributes 6. State your primary clinical diagnosis or Impression and differential diagnoses, if any, and discuss the rationale for each
PRIMARY CLINICAL IMPRESSION: Neonatal sepsis (i think ha! ill review pa later okay lang? -aaron) Ddx| R/I| R/O| Diagnostics|
(Early Onset Sepsis)| – risk factors for sepsis include: prematurity, maternal infection with GBS, UTI, prolonged rupture of membranes (>24hours prior to delivery), – male sex (4x more affected than female babies, possibly due to sex-link genetic basis) – low birth weight (2.3kg) along with prematurity are important neonatal predisposing factors to infection – may present with prominent respiratory signs: tachypnea, retractions, alar flaring, cyanosis – early onset sepsis presents in the 1st 5-7 days of life| – early onset sepsis is usually a multisystem fulminant disease
(-) fever| CBC
CXR – since the patient has respiratory symptoms|
* Early Onset Group B Streptococcus (GBS) Disease
(Invasive Neonatal GBS infection)| – presentation within the first 6 days of life. Most infants with Eo neonatal GBS become ill within the 1st 24 hours of life, as in the case. – association with maternal obstetric complications such as premature labor – prominent respiratory signs, regardless of the presence of pneumonia and include tachypnea, cyanosis, alar flare, intercostal retractions – maternal UTI during pregnancy (one of the risk factors include maternal bacteriuria during pregnancy, and GBS may also be the cause of UTI in pregnant and parturient women)
| * This diagnosis is established by isolation and identification of the organism from a normally sterile site such as blood, urine or CSF.
– GBS is not a very common cause of infections in newborns in the Philippines (source: http://www.babycenter.com.ph/a1647/group-b-streptococcus)| Culture and Sensitivity of GBS organisms obtained from blood, urine or CSF. – CSF should be examined in all neonates suspected of having sepsis bec. specific CNS signs are often absent in the presence of meningitis, esp. in early-onset disease. Antigen detection methods (e.g. latex particle agglutination) in urine, blood, CSF – less sensitive than culture Complete Blood Count – abnormalities in peripheral WBC count are frequently present including increased/decreased absolute neutrophil count, elevated band count, elevated ratio of bands to total neutrophils, leukopenia. Chest radiograph – findings are often indistinguishable from RDS and may include reticulogranular patterns, patchy infiltrates, generalized opacification, pleural effusions, or increased interstitial markings| Transient Tachypnea of the Newborn (TTN)|
– CS delivery
– 36 weeks
Respiratory distress symptoms occurring at 6 hours after birth
RR = 90/min [tachypnea]
Episodes of cyanosis
No other signs of sepsis| (TTN is often a diagnosis of exclusion and other causes of tachypnea should be excluded first).
*Acc. to the RDS trans, TTN does not usually have associated alar flaring, retraction, or increased work of breathing. Emed describes it as “quiet tachypnea” and says that cyanosis only occurs in extreme cases. This could help rule this out since the patient in the case exhibited increased work in breathing.| Radiologic Studies Chest Radiograph – shows parenchymal infiltrates, intralobar fluid accumulation, “wet silhouette around the heart”, hyperexpansion of lungs Lung Sonography – double lung point which is an ultrasound sign showing a difference in lung echogenicity between the upper and lower lung areas as well as very compact comet-tail artifacts in the inferior fields not present in superior fields
> mature lecithin to sphingomyelin ratio in amniotic fluid > presence of phosphatidylglycerol in amniotic fluid help rule out HMD
arterial blood gas – mild hypoxia, hypocarbia or mild hypercarbia (PCO2>55mmHg). if extreme hypercarbia present, other diagnosis should be considered CBC with differential – normal in TTN; should be obtained when considering an infectious process; hematocrit to rule out polycythemia urine and serum antigen tests – may help rule out certain infections interleukin-6 levels – initial IL-6 can distinguish proven and clinical sepsis from TTN
100% oxygen test – to rule out heart disease
Respiratory Distress Syndrome| – tachypnea, intercostal retractions, and cyanosis – preterm infant, 36wks by Ballard’s score| no sign of respiratory difficulty at birth (good cry)| Chest radiograph (AP view) – uniform reticulogranular pattern (ground glass appearance) accompanied by peripheral air bronchograms Blood gas sampling – intermittent arterial sampling, continuous transcutaneous oxygen and carbon dioxide monitors or oxygen saturation monitors Sepsis work-up – complete blood count and blood culture to rule out early onset sepsis Serum glucose levels – to assess adequacy of dextrose infusion; hypoglycemia alone can lead to tachypnea and respiratory distress Serum electrolyte levels including calcium – should be monitored every 12-24 hours for management of parenteral fluids; hypocalcemia can contribute to more respiratory symptoms and is common in sick, preterm infants.| Aspiration Pneumonia | – Pre-term infants (thus with immature sucking and swallowing reflexes) – History of breastfeeding before respiratory symptoms appeared – Signs of respiratory distress:
RR = 90/min [tachypnea]
Episodes of cy anosis
Intercostal retractions| No menitioned history of asphyxia, drooling, poor suck, vomiting or regurgitation|
Chest radiographs – pulmonary infiltrates CBC
Ultrasound – to determine presence of pleural effusion
Arterial blood gas – to assess oxygenation and pH status and adds information to guiding oxygen supplementation Serum electrolyte, blood urea nitrogen (BUN), and creatinine – to assess fhydration status|
7. Formulate a diagnostic management plan based on your clinical impression
– bacterial culture: takes 36-48 hours, but can appropriately identify bacterial pathogens. Note that urine cultures are used for late-onset sepsis (this case is early onset) – CBC- monitor thrombocytopenia, neutropenia, baselines, etc. Note that platelet count of a healthy newborn is rarely <100,000/uL. Also, WBC counts are nonspecific and have a low positive predictive value (normal WBC has been seen in culture/-positive sepsis) – C-reactive protein and other markers- CRP is an acute-phase protein that increases 4-6 hrs after onset of infection. It is associated with tissue injury, secondary to macrophage, T-cell or adipocyte production of IL-6. It is not used as a sole indicator for sepsis. Serum IgM may be used to indicate intrauterine infection – coagulation tests (PT, PTT)- to indicate DIC which can be common in infants – lumbar puncture with CSF analysis- warranted for both early- and late-onset sepsis.
If positive, a repeat test is done after 24-36 hours of antibiotic therapy. If still positive, modification of drug treatment may be necessary. CSF findings are elevated WBCs (predominantly PMNs), elevated protein, dec glucose and positive culture results). Note that CSF WBC can be within range in 29% of GBS (group B strep) meningitis but 4% in gram-negative meningitis, and protein and glucose levels can also be within range in 50% and 15-20% respectively as well. – imaging- CXR may show lobar or segmental infiltration but will more often show diffuse patterns as seen in respiratory distress syndrome. CT or MRI may be needed late in the course of a complex neonatal meningitis to document hydrocephalus, abscesses, or signs of chromic disease (ventricular dilation, atrophy, etc). Head ultrasound may be used to document ventriculitis, ECF, or other chronic chnages. Generally imaging does not help much in the initial onset of neonatal sepsis
8. Formulate and discuss the best principles of therapeutic management (including preventive measures) for this case.
*The following Tx Plan is for Neonatal Sepsis and are based on the trans/emedicine. Antibiotic Therapy
* *According to emed: begin antibiotics as soon as diagnostics are performed (recall from before that if you give antibiotics first it may interfere with results of culture, CSF studies, etc.)
* Empiric or initial coverage
* Penicillin derivative (Ampicillin) + Aminoglycoside (Gentamycin) OR Cefotaxime * Duration (general guidelines): For sepsis = 10-14 days (emed says 7-10 days) * If culture-negative susceptive sepsis + low index of suspicion = stop antibiotics after 48-72 hours. (if high index of suspicion = clinical judgement!)
* For significant anemia, thrombocytopenia, or coagulation problems: Transfuse blood products (packed red blood cells, platelets, fresh frozen plasma) * Maintain thermoregulation (IF with temperature instability)
* Adequate glucose control
* Support vital signs – constant monitoring
* Cardiopulmonary support and IV nutrition (in this case, does not seem warranted since there were no signs of poor feeding) may be required during acute phase until the patient stabilizes
*The trans discussed how to treat complications and adjunctive therapies (which, FYI, haven’t been supported by any substantial clinical trials. wala lang), but they don’t seem to be applicable here.
* Acyclovir (viral)
* Red blood cells should be administered to achieve a hemoglobin concentration of 13-16 g/dL in the acutely ill infant, to ensure optimal oxygen delivery to the tissues. * Delivery of adequate amounts of glucose and maintenance of thermoregulation, electrolyte balance, and other elements of neonatal supportive care are also essential. * Respiratory support
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