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NICU AUDIT

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. Anthropometrics. BW 1250 g BL 38 cm HC 26 cm CC 23 cm AC 21 cm MT 30, AGA

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NICU AUDIT

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  1. NICU AUDIT February 2014

  2. 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

  3. Anthropometrics • BW 1250 g • BL 38 cm • HC 26 cm • CC 23 cm • AC 21 cm • MT 30, AGA • AS 9,9

  4. 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

  5. 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

  6. Family History • DM • HTN Personal/ Social History • unremarkable

  7. OB History • G1- 2008, NSD, Full Term, male, BW 8lbs • G2- present pregnancy

  8. 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

  9. 2nd Hour of life

  10. 1st day of life

  11. 2nd day of life

  12. 3rd day of life

  13. 4th day of life

  14. 5thday of life

  15. 7thday of life

  16. CBC, hgt, chest xray

  17. 12thday of life

  18. 14thday of life

  19. CBC, hgt, chest xray

  20. 15thday of life

  21. (cont.) 15thday of life

  22. 16thday of life

  23. Current Diagnosis Prematurity, Very Low Birth Weight, Apnea of Prematurity, Sepsis, Mild Respiratory Distress Syndrome, Hyperbilirubinemia, unspecified, Resolved

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