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NICU AUDIT. February 2014. JPB. Born on February 14, 2014 Live preterm baby girl Delivered via Scheduled Primary Cesarean Section for Maternal Condition (Breast Cancer) 41 y/o G2P2 (1102) 2 8 5/7 weeks AOG. BW 1250 g BL 38 cm HC 26 cm CC 23 cm AC 21 cm MT 30, AGA AS 9,9.
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NICU AUDIT February 2014
JPB • Born on February 14, 2014 • Live preterm baby girl • Delivered via Scheduled Primary Cesarean Section for Maternal Condition (Breast Cancer) • 41 y/o • G2P2 (1102) • 28 5/7 weeks AOG • BW 1250 g • BL 38 cm • HC 26 cm • CC 23 cm • AC 21 cm • MT 30, AGA • AS 9,9
Maternal History • Chronic hypertensive for 24 years, usual BP 140-150 systolic • Feb 11, 2014- admitted at IMU for increase in BP given Methyldopa and Dexamethasone 10 mg every 12 hrs for 2 doses
Past Medical History • Feb. 2013 • noted to have a 2x3 cm mass on the left breast. • Mammography done showing “malignancy” but was lost to ff- up • Feb. 3, 2014 • Breast mass was increasing in size w/ engorgement of the breast • Biopsy done w/c showed Intraductal Carcinoma of the Left Breast, BIRADS 4 • Feb 12, 2014 • Ultrasound done: BPS 8/8, EFW 1305 g, Placenta anterior, grade 2, high lying, normohydramnios, Myoma 2.5X2.6 cm
Family History • DM • HTN Personal/ Social History • unremarkable OB History • G1- 2008, NSD, Full Term, male, BW 8lbs • G2- present pregnancy
Delivery • Apgar 1 min: HR >120’s, acrocyanotic, good cry and activity, spontaneous breathing • Apgar 5 min: HR >120’s, acrocyanotic, good cry and activity, spontaneous breathing • Immediately placed in a food grade plastic bag • O2 saturation: >85% • Newborn care was rendered
Current Diagnosis Prematurity, Very Low Birth Weight, Apnea of Prematurity, Sepsis, Mild Respiratory Distress Syndrome, Hyperbilirubinemia, unspecified, Resolved