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CASE DISCUSSION

CASE DISCUSSION. Legaspi , Luis Ontok , Abdul-Aziz Payumo , Edelissa Pelayo , May Angela Rodriguez, Melissa Samson, Edgardo. HISTORY. Identifying Data. Baby Boy J.C. Full Term, 37 weeks by P.A. 2600 g, appropriate for G.A. Cephalic presentation Repeat low-segment C.S.

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CASE DISCUSSION

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  1. CASE DISCUSSION Legaspi, Luis Ontok, Abdul-Aziz Payumo, Edelissa Pelayo, May Angela Rodriguez, Melissa Samson, Edgardo

  2. HISTORY

  3. Identifying Data • Baby Boy J.C. • Full Term, 37 weeks by P.A. • 2600 g, appropriate for G.A. • Cephalic presentation • Repeat low-segment C.S. • 23 year old, G2P2

  4. History of Present Illness • HR 60’s, limp, acrocyanotic, with no response • Thermoregulation, Suctioning, Tactile stimulation • HR 50’s, some flexion, acrocyanotic, (+) grimace • Thermoregulation, Suctioning, Tactile stimulation, PPV • HR 100’s,some flexion, acrocyanotic, (+) grunting • Thermoregulation, Given blow by O2, Stimulation • HR 130’s, active, acrocyanotic, (+) crying,RR 50-60 • Weaned off from O2 • (+) Grunting, (+) retractions • Placed on O2 support via 10 lpm • NICU 3

  5. Maternal Obstetrical History • OB Index: G2P2 (2002) • Previous Pregnancy: Date: 2007 Sex: Male BW: 2.7 kg Place: Perpetual Help Hospital Delivery Type: 1o Low-segment C.S. AOG: Full Term Complications: CephalopelvicDisroportion

  6. Antenatal History • LMP: September 04, 2008 • Prenatal Checkups: 2 at PGH • Medications Taken: None • Illnesses/Infection: None • Alcohol/Tobacco Use: None

  7. Labor • Onset of Uterine Activity: Spontaneous • Intensity of Contractions: Moderate • Membrane Status: Intact • Analgesia: None

  8. Delivery • Mode: Abdominal • Amniotic Fluid: Slightly Meconium Stained • Analgesia: Subarachnoid Block

  9. Immediate Neonatal Period • APGAR Score: 5, 9 • Resuscitation: • Supplementary O2 10 LPM via hood • Positive Pressure-Ventilation

  10. Family History • (-) Hypertension • (-) Diabetes Mellitus • (-) Bronchial Asthma • (-) Blood Dyscrasias

  11. PHYSICAL EXAMINATION

  12. GENERAL APPEARANCE: limp, in respiratory distress • VITAL SIGNS: T: 36.6oC HR: 130 bpm RR: 50 cpm Wt: 2600 g Lt: 49 cm HC: 32.5 cm CC: 31 cm AC: 28 cm • SKIN: acrocyanotic, (-) lesions, (+) cracking, rare veins

  13. HEAD: (-) molding, (-) cephalhematoma, both fontanels flat and soft, (-) overlapping sutures, BT: 8cm, BP: 9cm, SOB: 9cm, OF: 10.5cm, OM: 11.5cm • EYES: (-) discharges, anicteric sclerae, both pupils equally reactive to light • EARS: (-) low-set ears, formed, firm with instant recoil

  14. NOSE: (+) alar flaring, both nostrils patent, (-) discharges • MOUTH: (-) circumoral cyanosis, (-) cleft lip, formed tongue, (-) cleft palate • CHEST/LUNGS: (-) barrel-shaped, (+) subcostal & intercostal retractions, raised areola with 3-4 mm bud, (+) grunting,(-) tachypnea

  15. HEART: adynamic precordium, (-) thrills, normal rate, regular rhythm, (-) murmur • ABDOMEN: globular but not distended, nonpalpable liver • UMBILICUS: translucent, (-) meconium stained, 2 arteries and 1 vein • BACK: lanugo with bald areas, (-) dimpling, straight spine

  16. DIFFERENTIAL DIAGNOSIS

  17. PRIMARY WORKING IMPRESSION

  18. Full term, 37 weeks by PA, 2600 grams, AGA, Cephalic presentation, Delivered by repeat LSCS, APGAR Score 5,9 • Meconium Aspiration Syndrome vs. Neonatal Pneumonia • R/O sepsis

  19. COURSE IN THE WARD

  20. Catcher’s Area an extended-spectrum penicillin: improved activity against gram-negative organisms but can be destroyed by -lactamases -lactamase inhibitor has synergistic effect with penicillins • Born on May 7, 2009, 4:57 p.m. • Started on Piperacillin-Tazobactam (75mkd) 195 mg IV q12 • Started on Amikacin (15mkd) 40 mg IV OD

  21. Catcher’s Area Why? Why? Why? Why? Why? Why? Why? Why? • Diagnostics: > CBC with PC > Na, K, Cl, Ca, > Blood typing > CXR APL > ABG > Blood C/S • Venoclysis with D10W (80) @ 9cc/hr • NPO, Hgt q8 • O2 support at 10 lpm/hood

  22. Catcher’s Area COMPLETE BLOOD COUNT

  23. Catcher’s Area ARTERIAL BLOOD GAS COMBINED METABOLIC AND RESPIRATORY ACIDOSIS

  24. NICU

  25. 3rd Hour of Life S: (+) hypotension, (-) hypothermia, (-) dyspnea O: pink all over, some flexion of extremities, weak cry RR:24 HR:132 BP:30-40 T:36.6o O2:85-95% (-) alar flaring, (-) circumoral cyanosis equal chest expansion, (-) grunting, clear breath sounds adynamic precordium, (-) tachycardia, (-) murmur globular, soft, (-) masses good capillary refill, fair pulses A: Full term, 37 weeks by PA, 2600 grams, AGA, Cephalic presentation, Delivered by repeat LSCS, APGAR Score 5,9; Meconium Aspiration Sx vs. Neonatal Pneumonia

  26. 3rd Hour of Life P: • Given total of 50 cc PNSS IV bolus • Started on Dopamine @ 10mcg/kg/min to run for 1cc/hour (Dopamine 0.9cc + D5W 23.1cc) • UVC inserted

  27. 5th Hour of Life S: (+) persistent desaturation, (-) tachycardia, (+) dyspnea O: acrocyanotic, some flexion of extremities, weak cry RR:72 HR:144 BP:40-50 T:36.7o O2:80% (+) alar flaring, (-) circumoral cyanosis equal chest expansion, (+) ICS retractions, (+) grunting adynamic precordium, (-) tachycardia, (-) murmur globular, soft, (-) masses good capillary refill, fair pulses A: Full term, 37 weeks by PA, 2600 grams, AGA, Cephalic presentation, Delivered by repeat LSCS, APGAR Score 5,9; Meconium Aspiration Sx vs. Neonatal Pneumonia

  28. 5th Hour of Life P: • Intubated with MV settings: FiO2100%, 18/3, RR 60 LT 0.4 • D10W increased to run for 10 cc/hour

  29. 5th Hour of Life ARTERIAL BLOOD GAS (post-intubation) UNCOMPENSATED METABOLIC ACIDOSIS (NaHCO3 5 meqs)

  30. 7thHour of Life ARTERIAL BLOOD GAS (post-NaHCO3) COMPENSATED REPIRATORY ALKALOSIS

  31. 1st Day of Life S: (-) desaturation, (-) tachycardia, (-) dyspnea, (-) fever, (+) BM x1, (+) UO x2, (-) jaundice O: pink all over, good muscle tone, awake RR:56 HR:128 T:36.7o O2:99% (-) alar flaring, (-) circumoral cyanosis equal chest expansion, (-) ICS retractions, (-) grunting adynamic precordium, (-) tachycardia, (-) murmur globular, soft, (-) masses good capillary refill, strong pulses

  32. 1st Day of Life CHEST X-RAY CHEMICAL PENUMONITIS

  33. 1st Day of Life BLOOD CHEMISTRY HYPOCALCEMIA

  34. 1st Day of Life ARTERIAL BLOOD GAS COMPENSATED RESPIRATORY ALKALOSIS

  35. 1st Day of Life Why? A: Full Term, 37 weeks by PA, 2600 g, AGA, Cephalic presentation, Delivered by repeat LSCS, APGAR Score 5,9; Meconium Aspiration Syndrome vs. Neonatal Pneumonia; PPHN precaution; r/o Sepsis P: • IVF shifted to D10IMB Ca 300 @ 10cc/hr • Decreased RR to 50 then by 2 every 2 hrs until 30 • Decreased FiO2 by 5 every 2 hours until 60%

  36. 2nd Day of Life S: (-) desaturation, (-) tachycardia, (-) dyspnea, (-) fever, (+) BM x2, (+) UO x3, (-) jaundice O: pink all over, good muscle tone, asleep RR:44 HR:136 T:37.2o O2:99% (-) alar flaring, (-) circumoral cyanosis equal chest expansion, (-) ICS retractions, (-) grunting adynamic precordium, (-) tachycardia, (-) murmur globular, soft, (-) masses good capillary refill, strong pulses

  37. 2nd Day of Life ARTERIAL BLOOD GAS NORMAL ARTERIAL BLOOG GAS (????)

  38. 2nd Day of Life A: Full Term, 37 weeks by PA, 2600 g, AGA, Cephalic presentation, Delivered by repeat LSCS, APGAR Score 5,9; Meconium Aspiration Syndrome vs. Neonatal Pneumonia; PPHN precaution; r/o Sepsis P: • Once FiO2 60%, may start feeding with 5cc EBM every 3 hours per with strict aspiration precaution

  39. 2nd Day of Life P: • Start feeding 5cc EBM as ordered, if tolerated 3x, start increments: increase 5cc every feeding until 30cc • MV setting: 60% 18/5 26 0.4 • Wean FiO2 by 5 every 2 hours until 21% • Wean RR by 2 every 2 hours until 10 • Extract ABGs at RR=10

  40. 3rd Day of Life, A.M. S: (-) tachycardia, (-) dyspnea, (-) fever, (-) jaundice O: pink all over, good muscle tone, asleep RR:44 HR:136 T:37.2o O2:99% (-) alar flaring, (-) circumoral cyanosis equal chest expansion, (-) ICS retractions, (-) grunting adynamic precordium, (-) tachycardia, (-) murmur globular, soft, (-) masses good capillary refill, strong pulses A: Full Term, 37 weeks by PA, 2600 g, AGA, Cephalic presentation, Delivered by repeat LSCS, AS 5,9; MAS vs. Neonatal Pneumonia; PPHN precaution; r/o Sepsis

  41. 3rd Day of Life, A.M. ARTERIAL BLOOD GAS (post-extubation) ??????????????

  42. 3rdDay of Life, A.M. P: • Extubated • Placed on O2 hood FiO2 30% • Revised inotropes: Dopamine 0.5cc + D5W 23.5 cc to run at 1cc/hour, then consume, then discontinue • Racemic epinephrine nebulizationstarted, to continue 2 more doses 15 minutes apart

  43. 3rd Day of Life, P.M. S: (-) fever, (+) jaundice, (+) coffe-ground material/ogt O: pink all over, good muscle tone, asleep RR:48 HR:152 T:36.7o (-) alar flaring, (-) circumoral cyanosis equal chest expansion, (-) ICS retractions, (-) grunting adynamic precordium, (-) tachycardia, (-) murmur distended, soft, (-) masses good capillary refill, strong pulses A: Full Term, 37 weeks by PA, 2600 g, AGA, Cephalic presentation, Delivered by repeat LSCS, AS 5,9; MAS vs. Neonatal Pneumonia; PPHN precaution; r/o Sepsis

  44. 3rdDay of Life, P.M. P: • For TB DB IB • For CPT with proper shields • Dopamine discontinued • NCPAP 30% PEEP 5 • ABGs • Feeding decreased to 30cc

  45. 4th Day of Life S: (-) dyspnea, (-) fever, (+) jaundice, (+) vomiting O: pink all over, good muscle tone, asleep RR:44 HR:148 T:37.0o (-) alar flaring, (-) circumoral cyanosis equal chest expansion, (-) ICS retractions, (-) grunting adynamic precordium, (-) tachycardia, (-) murmur globular, soft, (-) masses good capillary refill, strong pulses A: Full Term, 37 weeks by PA, 2600 g, AGA, Cephalic presentation, Delivered by repeat LSCS, AS 5,9; MAS vs. Neonatal Pneumonia; Hyperbilirubinemia no set-up

  46. 4th Day of Life TOTAL, DIRECT, INDIRECT BIL. NORMAL

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