Pediatrics Rotation: Mubarak Hospital Case Report

Hessah AlHashash

210111055

Case Report

Pediatrics Rotation – Mubarak Hospital

17/9/2015

Case Report -1

Name: Marwan

Age: 16 days old “History taken on 14/9/2015”

Date of Birth: 30/8/2015

Sex: Male

*The history was taken from the mother

Presenting complaint:

Marwan, a 16 day old male neonate, presented to the Emergency with one day history of high grade fever, change in feeding, and drowsiness.

History of presenting complaint:

One day prior to his admission, his temperature was 37.5C “measured by digital monitor “on which his mother gave him paracetamol. The temperature went down to 36C for a short period of time. The day of his admission, his fever went up to 39C “Measured with a mercury thermometer in axillary region”. Associated with

Stopped the insulin after delivery. o Hypothyroidism: took 25g of thyroxin. Stopped the medication following delivery o Hospitalized in the 3rd trimester “8th month” for a Urinary Tract Infection and received a course of antibiotics.

Delivery History:

Spontaneous vaginal delivery and the baby was normal “didn’t require any emergency treatment or care”

Postnatal History:

• Weight:

o The CXR excludes that the cause is from a respiratory infection o The patient is hypothyroid which may explain the prolonged jaundice. The total bilirubin is high so it still needs to be monitored o Urinalysis shows increased WBC which most likely indicate that there is an infection in the urinary tract o The urine culture was positive for E.coli which is the most likely cause of the fever. o The U/S was most likely performed to check any abnormalities in the urinary tract and kidneys that might have predisposed the infection.

Treatment:

• Was admitted as a case of neonatal fever

• Full septic workup was done

• Started with Antibiotics and after identification of organism continued the medication.

• On the 7th day of claforan “cefotaxime”

Follow-Up:

• 19 days old , 5 days since admission

• Patient looks well

• Breastfeeding normally

• No fever, diarrhea, vomiting and no change in urine