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: Lionel Messi

Patient’s diagnosis: Haemorrhagic disease of newborn

Patient’s age: 2 days and 12 hours

Submitted by

Group No. , 5-year student

Lviv – 2023
. I.NEWBORN IDENTIFICATION
Baby Lionel Messi , male, born on 23/02/2023 at 12:00, weighing 3600 gm.

I. HISTORY
Prenatal information: Maternal age 28 years, gravida 2 para 1, no abortions, one living child. Blood type A
positive. Rhesus factor positive. No history of prenatal care.

Previous pregnancies: One living child, born at term without complications.

FAMILY HISTORY
Mother is married. Father's age 30 years, general health good. No
history of congenital malformations in siblings or chronic diseases.

DELIVERY:
Gestational age: 38 weeks. Onset of labor: Spontaneous.
Membranes: Ruptured spontaneously at the onset of labor. Clear amniotic fluid was noted.
Medications during labor and delivery: None.
Fetal presentation: Vertex presentation.
Duration of delivery: 5 hours.
Method of delivery: Vaginal delivery. Complications (maternal): None. Complications (fetal):
None.
Resuscitation: None required.
Post-delivery care: Erythromycin and Vitamin K1 IM were administered. Cord blood was sent
for serology, Coombs, blood group and Rh, bilirubin, and clotting factor levels.

Birth weight: 1100 gm Birth length: 27 cm

NEONATAL COURSE
The infant had no issues with transition after birth. On the second day after delivery, the infant was
noted to be irritable and had a large bruise on scalp. Laboratory investigations revealed a
prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT).
II. CURRENT PHYSICAL EXAMINATION
Age: 24 hrs after delivery
 Age: 2 days 12 hours after delivery
Measurements: Temperature: 37.2°C, RR: 44/min, HR: 144/min, SpO2: 98% on room air, weight: 3450
gm, head circumference: 36 cm (60th percentile), chest circumference: 34 cm (50th percentile),
length: 49 cm (75th percentile)
Skin: No cyanosis, pallor, or jaundice. Petechiae and ecchymosis noted on the lower limbs.
Head: Anterior fontanelle soft and flat. No sutural separation or overriding. No caput or molding. No
cephalhematoma.
Eyes: Bilateral subconjunctival hemorrhage. No discharge. Pupils equal, round, and reactive to light.
Red reflex present.
Ears: No pits or tags. Normal set and position. Bilateral canals patent without discharge.
Nose: Patent airway. No congestion or discharge.
Mouth: Pink moist mucosa. No cleft lip or palate. Tongue in midline. Normal frenulum and uvula.
Neck: Supple without lymphadenopathy or masses. No torticollis.
Chest: Symmetrical shape. No breast hypertrophy or abnormalities. Normal precordium. Regular heart
rhythm with no murmurs. Respiratory rate 44 breaths/min. Mild intercostal and subcostal
retractions. Decreased air entry over the right lower lobe with mild crackles.
Abdomen: Soft and non-tender. No distension or scaphoid shape. Normal umbilicus. No hernias. Liver
palpable 3 cm below right costal margin. No splenomegaly. Bowel sounds present.
Extremities: No edema or deformities. Full range of motion in all joints. Normal femoral pulses. No cyanosis or
acrocyanosis.
Skeletal system: No fractures or hip dislocations. No spinal dysraphism.
Neuromuscular: Alert and responsive. No lethargy, stupor, or coma. Normal tone in all extremities. No paralysis
or twitching. Cranial nerves intact. No seizures. Reflexes: Moro and tonic neck reflex present. Stepping, placing,
rooting, sucking, palmar, and plantar grasp reflexes present.
Genitalia: Male, normal penis and scrotum, testes descended bilaterally, no hydrocele, no hypospadias, no
torsion.
Anus: Patent with passage of meconium. No abnormalities.

IV. IMPRESSION/ASSESSMENT (preliminary clinical diagnosis based on

the data above and it’s substantiation)

The patient is a 2-day-old neonate with a birth weight of 3600 gm and gestational age of 38 weeks. He presents with
petechiae and ecchymosis on the lower limbs and decreased air entry over the right lower lobe with mild crackles. The
preliminary clinical diagnosis is Hemorrhagic disease of a newborn, likely due to vitamin K deficiency, which is further
substantiated by the lack of vitamin K prophylaxis at birth and normal coagulation studies. The patient will require further
workup and management.

V. MANAGEMENT PLAN of the all identified clinical problems

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

Investigations:
Prothrombin time (PT) and activated partial thromboplastin time (aPTT) to assess coagulation factors
Complete blood count (CBC) to assess platelet count and hematocrit levels
Coagulation factor assays to assess levels of specific clotting factors
Liver function tests to assess liver function
Treatment:
Vitamin K1 injection (1mg) given intramuscularly to correct the deficiency of vitamin K in newborns.
Fresh frozen plasma (FFP) transfusion to replace clotting factors in case of severe deficiency or bleeding.
Platelet transfusion if the platelet count is critically low. Monitoring of coagulation parameters to adjust treatment as
needed.
Feeding:
Breastfeeding or formula feeding every 2-3 hours to maintain adequate nutrition and hydration.
Iron supplementation to prevent anemia.
 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.