1. General Information  NF  2 months/female  Filipino  Roman Catholic  Sapang Palay, Bulacan  DOB: July 1, 2014  DOA: September 6, 2014

2. CHIEF COMPLAINT Fecaloid discharge from post-op site

3. History of Present Illness  Diagnosed case of Gastroschisis  Admitted at our NICU from July 2014 to August 20, 2014, discharged apparently well, with weight of 2.2 kg, fed with purchased EBM from milk bank  Seen at the Neonatology OPD 7 days PTA, advised admission due to dehydration; admitted for 1 day at our ER and discharged apparently well  1 day PTA, mother noted fecaloid material coming out from post-operative site  Persistence prompted consult to our ER

4. History of Present Illness 10 hours prior to admission Fever, Tmax: 38.2 ˚C Fecaloid material from post-op site No cough, colds, no vomiting No bowel movement, last BM was 1 day PTA Poor suck and activity No consult done No meds given

5. History of Present Illness two hours PTA Post-op wound with surrounding erythema, which continuously draining fecaloid discharge (+) fever Poor suck and activity ADMISSION

6. Review of Systems  General: poor weight gain  HEENT: No ear discharge, no colds, good suck  Cardiac: No cyanosis when feeding  GI: (+) changes in the consistency of the stools  GU: no decrease in urine output, no changes in the color of urine  Hematologic: No pallor, occasional and minimal bleeding on the lesions on the inguinal area  Musculoskeletal: No muscle weakness, no joint swelling  Neurologic: No seizures

7. Birth and Maternal history  Born to a 18 y/o G2P2 (2002), nonsmoker, nonalcoholic beverage drinker.  regular PNCU since 2 months AOG at a LHC, attended by a midwife.  with intake of MVS, FeSO4  UTZ at 5 months AOG, (+) protruding mass over umbilicus  No maternal illness noted  No Congenital Scan

8. Birth and Maternal History  Delivered full-term, via NSD at Sapang Palay District Hospital c/o midwife, with good cry and activity  (+) abdominal wall defect with gastric contents protruding, lateral to the umbilicus  Given Erythromycin ointment, OGT inserted, gastric contents wrapped in a gauze soaked in PNSS, advised THOC to PCMC  Admitted at the Neonatal ICU for 1 1/2 months

9. Family History 2930 2mos No history of Hypertension, DM, Bronchial Asthma, Allergy, Malignancy, Seizure disorder 2 y/o

10. Immunization History  BCG x 1 dose  Hep B x 1 dose

11. Nutritional History  Started on EBM at birth fed through OGT, shifted to formula feeding Bona 1:2 dilution, 4oz q4  No residuals. No swallowing difficulties

12. Developmental History  Gross motor  Poor head control  Fine motor  fisting  Language  coos  Personal Social  No social smile

13. Personal Social History  Lives in a well lit, well ventilated house with extended family on the paternal side, together with 7 household members  Primary caregiver: Mother  Source of water: tap water  Garbage collected twice a week  House not near factories and highways

14. Past Medical History  Previously admitted at our NICU: last July 3, 2014 to August 18, 2014 due to Gastroschisis, s/p emergency application of IV bag, s/p abdominal wall closure using MESH 7/25/2014, Sepsis (Candida), resolved; AKI due to Sepsis, resolved; SSI (p. Aeruginosa), resolved  Readmission last August 28, 2014 due to AGE, admitted for 1 day at our ER

15. Physical Examination on Admission  General Survey: awake, not in respiratory distress  Wt: 2.0 kg (z score: <-2 )  VS:  Temp 36.0  CR 122  RR: 41

16. Physical examination  Skin: no jaundice, no cyanosis  HEENT: No skull deformities, (+) sunken fontanels, anicteric sclerae, (+) pale palpebral conjunctiva, no eye discharge, (-) ear discharge, no alar flaring, moist lips and tongue, no buccal mucosal lesions, no tonsillopharyngeal congestion  Chest: symmetric chest expansion, shallow subcostal and intercostal retractions, clear breath sounds

17. Physical examination  Heart: adynamic precordium, no heaves, thrills or lifts, normal, regular rhythm, no murmurs  Abdomen: globular abdomen, normoactive bowel sounds, (+) fecaloid material from post-operative site, greenish pasty output approximately 10ml  Extremities: Faint pulses, cold extremities, no cyanosis, no edema, CRT <2 secs  Neurologic exam: intact cranial nerves, spontaneous movement of both extremities, normoreflexive, no nuchal rigidity, no nystagmus

18. Admitting Diagnosis at the Wards Gastroschisis, s/p Abdominal Wall Closure using MESH (7/25/2014), Sepsis, Healthcare- Acquired Infection

19. Course in the Wards

20. Course in the wards 1st HD

21. Course in the wards 2nd HD

22. Course in the wards 3rd HD

23. Course in the wards 4th HD

24. Course in the wards 5th HD

25. Course in the wards 6th-7th HD

26. Course in the wards 8th HD

27. Course in the wards 9th HD

28. Course in the wards 10th HD

29. Course in the wards

31. Final Diagnosis  Septic Shock  Disseminated Intravascular Coagulation  Healthcare Acquired Infection  Failure to thrive