Danylo Halytsky Lviv National Medical University

Department of Pediatrics No. 2

Guidelines for student individual work

Academic Year 5th

for specialty 222 "MEDICINE"

Topic: “Guideline for writing the case report for 5-year medical students”

Hours: 2

Approved at the Meeting of the Department

Protocol No.1 of “29” of August 2022

Lviv – 2022
DANYLO HALYTSKY L’VIV NATIONAL MEDICAL UNIVERSITY
Department of Pediatrics No. 2

Department Head
Prof. L. Besh

Tutor
 Guideline for writing the Learning Medical Record for 5-year medical
students

Patient’s name: Sachin Tendulkar

Patient’s diagnosis: Perinatal asphyxia; HIE stage II. IUGR.

Prematurity 36 wks.
Hypoglycemia.

Patient’s age: 48 hours after delivery

Submitted by
Ammu Jojo

Group No. 10, 5-year student

Lviv – 2023
I.NEWBORN IDENTIFICATION
Baby Sachin Tendulkar, male, born on 01/01/2023 at
GeneralHospital weighing 1500g, and measuring 43cm in
length.

I. HISTORY
Prenatal information: The mother is 28 years old and this is her first pregnancy. She had adequate prenatal
care and received regular antenatal checkups. The mother has no history of chronic illnesses or pregnancy-
related complications. Blood tests including Coombs, serology, and other blood tests were normal. The GBS
status of the mother was negative. The estimated due date (EDC) was 02/14/2023, and the last menstrual
period (LMP) was on 05/09/2022.

Delivery: The baby was delivered via emergency cesarean section due to fetal distress. The membranes were
artificially ruptured, and the amniotic fluid was clear. Medications including antibiotics for GBS prophylaxis
were given during labor and delivery.

Complications: The mother had a fever during labor, and a diagnosis of chorioamnionitis was made. The
baby had perinatal asphyxia with HIE stage 2, intrauterine growth restriction (IUGR), and hypoglycemia.
The baby's Apgar scores at 1 and 5 minutes were 3 and 5, respectively.

Previous pregnancies: N/A

FAMILY HISTORY:

Marital status of mother: married

Father: age 38 years old, general health good, same father for previous pregnancies
Siblings: no known congenital malformations or chronic diseases
DELIVERY:

Gestational age: 36 weeks

Onset of labor: spontaneous
Membranes: ruptured spontaneously, clear amniotic fluid
Medications during labor and delivery: none
Fetal presentation: cephalic
Duration: 1st stage 6 hours, 2nd stage 2 hours, 3rd stage 15 minutes
Method of delivery/indication for method: vaginal delivery, indication for method: fetal distress
Complications (maternal): none reported
Complications (fetal): fetal distress, meconium-stained amniotic fluid
Resuscitation: required, oxygen, bag and mask, Apgar scores 3 and 5 at 1 and 5 minutes,
respectively
Post-delivery care: erythromycin ointment to eyes, vitamin K1 injection, cord blood sent for
serology, Coombs, blood group and Rh, bilirubin (optional), passage of meconium and
urine noted
Birth weight: 1500g
Birth length: 43 cm

NEONATAL COURSE:
 Problems of transition: perinatal asphyxia, hypoglycemia
Diseases: hypoxic ischemic encephalopathy stage 2, intrauterine growth restriction (IUGR)
Diagnostic and treatment measures: mechanical ventilation, antibiotics, anticonvulsants
Treatment effectiveness: improvement in respiratory and metabolic status, persistent
encephalopathy

II. CURRENT PHYSICAL EXAMINATION

Age: 48 hours after delivery

Measurements: Temperature 36.7°C, RR 60/min, HR 150/min, SpO2 98% in room air, weight 1500g,
head circumference 28cm (10th percentile), chest circumference 26cm (3rd percentile), length 43cm (10th
percentile).

Skin: Jaundice present, no cyanosis, pallor or rashes noted.

Head: Fontanelles soft, no abnormal head shape, no cephalhematoma. Mild hypotonia noted.

Eyes: No discharge, pupils equal and reactive to light, red reflex present.

Ears: Normal pinna, no pits or tags noted.

Nose: Patent airway, no congestion or discharge.

Mouth: Lips, tongue and frenulum normal, palate intact, no cleft lip or palate.

Neck: Supple, no masses or sinuses, no torticollis noted.

Chest: Asymmetrical chest movement, no respiratory distress, no murmurs, regular rhythm, pulses
normal.

Lungs: Respiratory rate 60/min, no retractions, mild grunting, asymmetric breath sounds with rales
present.

Heart: Regular rhythm, tachycardic with no murmurs or gallops, pulses normal.

Abdomen: Soft, scaphoid, umbilical hernia present, liver and spleen not palpable, no masses, bowel
sounds present.

Extremities: No edema, normal femoral pulses, no dysmorphic features noted, mild hypotonia noted.

Skeletal system: Normal sinuses, no fractures or hip dislocation, no spinal dysraphism.

Neuromuscular: Lethargic, hypotonic, no clonus, brisk deep tendon reflexes, positive Babinski sign,
absent Moro and rooting reflexes.

Genitalia: Male with normal penis and testes.

Anus: Patent, no meconium, no abnormalities.

IV. IMPRESSION/ASSESSMENT (preliminary clinical diagnosis based on

the data above and it’s substantiation)
Perinatal asphyxia with HIE stage 2, IUGR, prematurity 36 weeks, and hypoglycemia. Neonatal jaundice, umbilical hernia,
and mild respiratory distress with rales noted. Neurological examination is concerning for hypoxic-ischemic
encephalopathy with hypotonia and absent reflexes.

V. MANAGEMENT PLAN of the all identified clinical problems

including investigation, treatment, and detailed feeding
administration with all calculations

Investigations:

● Blood gas analysis to assess acid-base balance and oxygenation status.

● Serum glucose levels to monitor hypoglycemia.
● Complete blood count to assess anemia and infection.
● Cranial ultrasound to evaluate for intraventricular hemorrhage and other intracranial abnormalities.
● Electroencephalogram (EEG) to evaluate for seizures.

Treatment:

● Oxygen therapy to improve oxygenation and tissue perfusion.

● Intravenous fluids to maintain adequate hydration and electrolyte balance.
● Glucose supplementation to maintain normal serum glucose levels.
● Antibiotics to treat or prevent infections.
● Anticonvulsants to prevent seizures.
● Nutritional support with breast milk or formula, given by nasogastric tube or bottle.
● Feeding Administration:
● The baby will receive enteral feedings of breast milk or formula every 2-3 hours. The feeding amount will be
calculated based on the baby's weight and will be increased gradually to meet the baby's nutritional
requirements.
 Appendix 1
PATIENTS’ DATA

Student # 1
Gestational age: 30 wks
Birth weight: 1100 gm Birth length: 27 cm
Current physical examination age: 24 hr after delivery
Preliminary clinical diagnosis: Severe RDS. IVH grade 3. Prematurity 30 wks.

Student # 2
Gestational age: 38 wks
Birth weight: 3800 gm Birth length: 27 cm
Current physical examination age: 36 hr after delivery
Preliminary clinical diagnosis: Rh hemolytic disease of a newborn.
 Student # 3
Gestational age: 40 wks
Birth weight: 4200 gm Birth length: 55 cm
Current physical examination age: 3 days after delivery
Preliminary clinical diagnosis: Birth trauma. Subdural hemorrhage. Erb’s palsy.

Student # 4
Gestational age: 36 wks
Birth weight: 1500 gm Birth length: 43 cm
Current physical examination age: 48 hr after delivery
Preliminary clinical diagnosis: Perinatal asphyxia; HIE stage II. IUGR. Prematurity 36 wks.
Hypoglycemia.

Student # 5
Gestational age: 38 wks
Birth weight: 3600 gm Birth length: 49 cm
Current physical examination age: 2 days 12 hr after delivery
Preliminary clinical diagnosis: Hemorrhagic disease of a newborn.

Student # 6
Gestational age: 36 wks
Birth weight: 2200 gm Birth length: 44 cm
Current physical examination age: 24 hr after delivery
Preliminary clinical diagnosis: Early neonatal sepsis. Prematurity 36 wks.

Student # 7
Gestational age: 35 wks
Birth weight: 1400 gm Birth length: 41 cm
Current physical examination age: 36 hr after delivery
Preliminary clinical diagnosis: Congenital CMV infection. IUGR. Prematurity 35 wks.

Student # 8
Gestational age: 36 wks
Birth weight: 2100 gm Birth length: 43 cm
Current physical examination age: 4 days after delivery
Preliminary clinical diagnosis: Congenital toxoplasmosis. Prematurity 36 wks
Student # 9
Gestational age: 36 wks
Birth weight: 2300 gm Birth length: 43 cm
Current physical examination age: 3 days after delivery
Preliminary clinical diagnosis: Congenital Syphilis. Prematurity 36 wks.

Student # 10
Gestational age: 30 wks
Birth weight: 1500 gm Birth length: 37 cm
Current physical examination age: 20 days after delivery
Preliminary clinical diagnosis: Late Neonatal Sepsis. Meningitis. Prematurity 30 wks.

Student # 11
Gestational age: 40 wks
Birth weight: 4000 gm Birth length: 51 cm
Current physical examination age: 49 hr after delivery
Preliminary clinical diagnosis: ABO hemolytic disease of a newborn; jaundiced clinical form.

Student # 12
Gestational age: 43 wks
Birth weight: 3800 gm Birth length: 52 cm
Current physical examination age: 72 hr after delivery
Preliminary clinical diagnosis: Intrapartum asphyxia: HIE III. Postmaturity.
 Student # 13
Gestational age: 29 wks
Birth weight: 1200 gm Birth length: 38 cm
Current physical examination age: 72 hr after delivery
Preliminary clinical diagnosis: RDS. PDA. Prematurity 29 wks.

Student # 14
Gestational age: 36 wks
Birth weight: 2400 gm Birth length: 45 cm
Current physical examination age: 10 hr after delivery
Preliminary clinical diagnosis: TTN. Prematurity 36 wks.

Student # 15
Gestational age: 34 wks
Birth weight: 1800 gm Birth length: 40 cm
Current physical examination age: 24 hr after delivery
Preliminary clinical diagnosis: Congenital pneumonia. Prematurity 34 wks.