General Data Baby L. Male Preterm 23 2/7 AOG Delivered via scheduled NSD to a 32 year old G1P1 (0101) September 16, 2013 (12:31 pm)

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Presentation transcript:

General Data Baby L. Male Preterm 23 2/7 AOG Delivered via scheduled NSD to a 32 year old G1P1 (0101) September 16, 2013 (12:31 pm)

Prenatal History 1 st trimester-Urinary tract Infection treated with antibiotics x 7 days weeks AOG, had preterm labor admitted for 5 days ( Aug 22-27, 2013) sent home on Isoxuprine s/p Dexamethasone x 2 doses

Past Medical History 2005, diagnosed of PCOS on OCP Primary Infertility treated with Clomiphene 2010, 2011, s/p D&C for thickened endometrium Family History Diabetes

minute 5 minute10 minute15 minute

Physical Examination Vital signs: CR: 110 bpm RR: 31 cpm Temp: 34.5 Anthropometrics: Weight: 635 g Birth length: 31 cm Head circumference: 22 cm Chest circumference: 19 cm Abdominal circumference: 18 cm Appropriate for Gestational Age

MT= 24 AOG

Physical Examination SKIN: gelatinous red, translucent HEENT: no deformity, lids are fused CHEST/LUNGS: symmetrical chest expansion, subcostal and intercostal retractions, equal air entry HEART: good cardiac tone ABDOMEN: Soft, globular, umbilical stump with 2 arteries, 1 vein GENITALIA: bilaterally undescended testis, minimal rugae EXTREMITIES: no deformity

Admitting Diagnosis Preterm Baby Boy delivered via NSD to a 32 y/o G1P1 (0101) at 23 2/7 weeks AOG; Incredibly Low Birth Weight

SubjectiveObjectiveAssessmentPlan Day 0 of lifeVS: HR 110 RR 31 T 34.5 Intubated, minimal spontaneous respiration Gelatinous red Flat fontanelles Subcostal and Intercostal retractions Equal air entry Good cardiac tone Soft abdomen Cold extremities Fair Pulses Preterm Baby Boy Incredibly Low Birth Weight Hooked to Mechanical Ventilation Fi PIP 14 PEEP 5 FR 10 RR 30 Intravenous Fluids Umbilical Vein Cannulation CBC, Blood Culture, EG7 Chest Xray Thermoregulation

SubjectiveObjectiveAssessmentPlan 2 nd Hour of life 3 rd Hour of life ASYSTOLE ON ECG VS: HR 0 RR 0 hypothermic Intubated, No spontaneous respiration Gelatinous red Flat fontanelles Poor to no air entry No cardiac tone Soft abdomen Cold extremities No Pulses Preterm Baby Boy Incredibly Low Birth Weight Pneumothorax Epinephrine IV Continuous ambubagging Needling for pneumothorax

Final Diagnosis Cardiopulmonary Arrest 2 to Bilateral Pneumothorax; Severe Respiratory Distress Syndrome; Incredibly Low Birth Weight; Extreme Prematurity