Pediatrics Rotation: Mubarak Hospital Case Report

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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
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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:
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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

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