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General Data

General Data. Baby Girl of Ara Joy Guray , 6 th DOL, currently admitted at NICU 2. History of Present Illness.

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General Data

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  1. General Data Baby Girl of Ara Joy Guray, 6th DOL, currently admitted at NICU 2.

  2. History of Present Illness • Born Pre-term, 36 weeks by pediatric aging, 1450 grams, small for gestational age, breech presentation, delivered by primary LSCS, live baby girl, APGAR 6,8 to a 27 yo, G2P1 (1001) mother. • Mother had regular (10x) prenatal check-up c/o LHC. Had UTI at 7 mos AOG, treated with Antibiotics. No other disease during pregnancy. No exposure to radiation. (+) intake of MVT. 1 Day prior to delivery, mother was admitted to Intensive Maternal Unit for Preterm labor, PU 35 3/7 by EUTZ.

  3. History of Present History • Received limp, acrocyanotic with weak cry. Supportive management (thermoregulation, suctioning, positioning, stimulation) was administered. After 30s, HR was 90’s with poor respiratory effort. Supportive management continued. Still with HR of 110 after 1 min, positive pressure ventilation was administered. HR improved to 150s and with regular respiration. At 5 min, (+) subcostal retractions, placed on 02 at 10 lpm. (-) grunting but still with (+) subcostal retractions. Hence admitted to NICU3.

  4. Course at the NICU Admitted to NICU 3 with the diagnosis of: Preterm, 36 weeks by PA, 1450 g, small for gestational age, breech presentation, delivered via 1 LSCS, Live Baby Girl, APGAR 6,8. TTN vs Neonatal Pneumonia r/o sepsis

  5. Course at the NICU • Labs facilitated CBC BT Blood CS ABG Na K KCl Ca • Medications started Amikacin (25) 40mg IV q12h Imepenem (15) 20mg IV OD • On IVF: D10 W at 4-5 cc/kl with Hgt q8

  6. Course at the Nicu • Placed on NCPAP 60% at PEEP 5 upon admission. ABG done which showed acceptable blood gas with no hypoxemia. Weaning of FI02 by 5 q2 until 21 while maintaining 88% of O2 saturation. • IVF was shifted to D10IMB Ca300 at 5cc/hr. Trophic feeding was also initiated with 4cc q3.

  7. 1st DOL • Clear breath sounds, comfortable • Dx: ff-up Labs • Tx: Imipenem, Amikacin • Shifted O2 support to 1 lpm/nasal cannula. • Plan to transfer pt to NICU 2.

  8. 2nd DOL • Clear breath sounds, comfortable, (+) jaundice • Dx: TB DB IB • Tx: Imipenem, Amikacin • On room air • Plan: transfer pt to NICU 2, increase feeding

  9. 3rd DOL • (+) fever of 38.9 C, with irregular respiration. • Placed on 02 support at 2-3lpm/nasal cannula • Dx: CBC, Blood CS, Babygram APL, TB DB IB • Tx: Imipenem, Amikacin, t/s Ciprofloxacin (10) 13.5mg IV q12 Lab Results: Babygram: Nosocomial Pneumonia TB DB IB: 18.99 1.11 17.88

  10. 3rd DOL A> PT, 36 weeks by PA, 1450g, SGA, breech, LSCS LBG, AS 6,8 TTN r/o sepsis Hyperbilirubemiaprob physiologic vs ABO incompatibility vs sepsis t/c Nosocomial sepsis Plan: Continue Phototheraphy, Increase Feeding

  11. 4th DOL • On trial of room air. Continued Antibiotics treatmnet (Imipenem D4, Amikacin D4, Cipro D1) • Latest labs: TB 16.5, DB 0.87, IB 15.6 • Plan: continue phototherapy, increase feeding

  12. 5th DOL • Decrease jaundice. Clear breath sounds. (-) retractions. • On room air • Dx: repeat TB DB IB • Tx: Imipenem, Amikacin, Cipro • A: PT, 36 wks by PA, 1450g, SGA, breech del via LSCS AS 6,9. TTN resolved, Nosocomial pneumonia resolving, r/o sepsis. • Plan: continue phototherapy, transfer to NICU 2, increase feeding

  13. 6th DOL • Asleep, comfortable, (-) tachypnea/retractions • Decrease jaundice. • Transferred to NICU 2 • Dx: for TB DB IB • Tx: Imipenem D6, Amikacin D6, Cipro D2 • Plan: Continue phototherapy, incraese feeding

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