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M. G.

M. G. Marissa A. Resulta , M.D. History of present illness. M.G., newborn, male preterm from a 34 year old G1P0 Outlet forceps extraction sec to preeclampsia 8 th hr of life, (+) swelling on the right scalp Admitted to NICU 2. Physical Examination. Awake, crying, fair activity

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M. G.

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  1. M. G. Marissa A. Resulta, M.D.

  2. History of present illness • M.G., newborn, male • preterm from a 34 year old G1P0 • Outlet forceps extraction sec to preeclampsia • 8th hr of life, (+) swelling on the right scalp • Admitted to NICU 2.

  3. Physical Examination • Awake, crying, fair activity • HR: 160 RR 40 T 36.5 C Wt: 1850 grams HC: 31 cm CC: 25cm AC: 22cm L: 46cm • (+) caput occipitoparietal, right (+) abrasion mid occiput, anterior fontanelle soft & flat • Symmetrical chest expansion, no retractions, clear breath sounds, no crackles, no wheezes • Adynamicprecordium, distinct heart sounds, normal regular rhythm, no murmur • Soft abdomen, no organomegaly • Full & equal pulses, no fractures

  4. Course at the NICU: Hematologic • S: (+) pallor (+) jaundice • O: asleep, arousable • HR: 162 RR: 50 T 36.5 • (+) scalp swelling right, occiput • A: Anemia secondary to acute blood loss • P: Dxtics: Cranial CT scan, CBC, ABG, PT/PTT, BT TFI- 80- increased to 120, given 40cc/kg) PNSS • Hook to O2 at 0.5 lpm NC • BT of pRBC (15cc/kg) & FFP • Vitamin K (1) • Dopamine (5) – (8)

  5. Cranial CT scan: diffuse extracalvarial soft tissue swelling with note of hyperdensities (hematoma) in the right high parietal region. • ABG: 7.405/ 26.3/ 125.3/ 16.4/ -6.2/ 98.4% • CBC:67/0.225/8.27/0.67/ 0.18/ 0.11/ 0.01/ 123 • PBS: mod hypochromia, mod anisocytosis, marked poikilocytosis, (-) toxic granulation • PT/PTT: 12.6/ 17.2/ 0.45/ 1.56 • 34.9/ 60.7 • Blood type O+

  6. Assessment • Preterm, 34 weeks by pediatric aging, 1850 grams, appropriate for gestational age, cephalic, delivered via outlet forceps extraction secondary to severe preeclampsia, live baby boy apgar 3, 7 Subgaleal hematoma

  7. Course at the NICU: Infectious • S: D6 (+) apnea (+) cyanosis (+) bradycardia • O: HR: 160s • (+) milk/ orem & OGT • Clear breath sounds, (-) retractions • A: Aspiration pneumonia r/o nosocomial sepsis • P: Dxtics: CBC, Blood CS, babygram • Hook to 2 NCPAP 40% PEEP 5 • Meropenem (40) • Amikacin (15) • Pentoxifylline • Dopa (5)- Dobu (5)

  8. Hematologic • S/O: 1st week of life: (+) jaundice • Total Bilirubin: 15.02 • PT/PTT: 12.6/ 17.2/ 0.45/ 1.56/ 34.9/ 60.7 • A: Hyperbilirubinemia sec to subgaleal hematoma • P: BT pRBC & FFP • phototherapy • Difficulty in IV insertion- UAC • Umbilical vein catheterization x2 weeks

  9. Cardiac/ Infectious • S: 11th DOL: (+) grade 3/6 holosystolic murmur • O: HR: 168 RR 60 T 37.8 C • 2D echo: oscillating mass attached to the tricuspid valve measuring 3.5cm in diameter. No pericardial effusion. Good biventricular contractility. • A: Infective endocarditis (iatrogenic) • P: Remove UVC • Dxtics: Blood CS x 2sites-(+)yeast cells after 1.5hrs • ESR, CRP, CXR APL • Txtics: Meropenem (40) • Vancomycin (40)- (60) • Fluconazole (12) – (6) to Ampho B

  10. 5/12: Large vegetation attached to the tricuspid valve at the right atrium measuring 2x1.3cm. Mild tricuspid regurgitation. • 40th DOL: intubated ET 3.5 L8 • InotropesDopa & Dobu • 5/17: Infective endocarditis at the right atrium measuring 2.5/1.6 cm with mild TR & TS.

  11. Circumstances surrounding the demise • Referred for HR: 0 • (+) fresh blood/ OGT, ET • Code called • Given Epinephrine per ET/ OGT • Inotropes Dopa10-20, Dobu 10-20, Epi 1 • Given total of 65cc/kg PNSS & 2meqs NaHCO3 • Patient never revived.

  12. Probable cause of death • Disseminated intravascular coagulopathy secondary to septic emboli (sec to umbilical catheterization)

  13. Provisional autopsy result • Diffuse alveolar damage secondary to pneumonia • Fungal endocarditis (Candida albicans) secondary to umbilical catheterization • Septic embolism

  14. Blood CS • 4/26: (+) Candida sp after 1.52 hrs (+) yeast cells • 5/4: (+) Candida sp after 1.16 hrs • 5/11: (+) Candida albicans after 2 hrs • 5/20: GS: (+) for gram (-) bacilli CS: (+) Klebsiellapneumoniae after 3 hrs Sensitive: Amikacin, Ertapenem, Meropenem Intermediate: Ciprofloxacin Resistant: Amoxi-Clav, Ampi, Ampi-Sul, Aztreonam, Cefoxitin, Cefepime, Ceftazidime, Ceftriaxone, Cefuroxime, Gentamicin, Trimethoprim

  15. Complete Blood Count

  16. Complete Blood Count

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