MENDOZA, Baby boy

Maternal History Patient was born to a 26 y/o primigravid delivered via 1 0 LSCS in PGH PNCU c/o PGH Noted macrocephaly and hydrocephalus at 6 mo AOG thru UTZ No known maternal illness during pregnancy Intake of folic acid started at 2 mo AOG Ruptured BOW 1 ½ hrs prior to delivery

Birth History Born full term, 37 wks by PA, BW of 2850g, AGA, breech presentation, APGAR 6,8 Noted at birth multiple congenital anomalies (hydrocephalus, spina bifida)

PE at birth HEENT – Macrocephalic; anterior fontanelle open soft and flat; pink conjunctivae; anicteric sclerae; grossly normal eyes, ears, nose, mouth; (-) cleft lip/palate HR130sRR30s BW2850gBT11cm LT50cmBP13cm HC44cmSOB13cm CC29cmOF11cm AC28cmOM12cm

PE at birth Chest – Equal chest expansion, (-) retractions, clear breath sounds Heart – Adynamic precordium, distinct heart sounds, normal rate regular rhythm, (-) murmur Abdomen – Globular, normoactive bowel sounds, soft, no palpable masses

PE at birth Back – (+) tuft of hair, skin defect in lumbar area exposing spinal cord Skin/Extremities – Full and equal pulses, pink nailbeds, no jaundice, (-) polydactyly/syndactyly Genitalia – Grossly normal male external genitalia; patent anus

PE at birth Neuro exam – No eye opening, fair cry, (+) movement of upper extremity, fair activity – Pupils 3mm EBRTL – (-) Moro reflex – (+) Babinski, bilateral – DTRs: ++

Course Patient received acrocyanotic, HR 110, with some flexion, grimace, and irregular breathing Further neonatal resuscitation done and after 5 minutes  noted HR 130s, with regular breathing, active movement, fair cry, and acrocyanosis A> FT, 37 wks by PA, 2850g, AGA, breech, del via 1 LSCS, live baby boy, APGAR 6,8; MCA (hydrocephalus, spina bifida) Patient was then admitted to NICU2.

Course Newborn care was started. Lab work up done (CBC, BT, Blood CS). Therapeutics started were as follows: Meropenem (40), Amikacin (15), Vancomycin (15). Feeding with 29cc EBM/OGT q3 started. At the NICU, assessment was Spina bifida, occulta vs meningocoele, t/c Dandy Walker, Congenital Hydrocephalus

Course Plan is for thoracolumbar xray. Referral to NSS and Neuro service done. On the 1 st day of life, patient was referred for bradycardia and apnea. Patient was then hooked to NCPAP (40%, 5). Serial ABGs done. However, still with irregular respiration and noted desturation (O2 sats of 40s). Patient was transferred to NICU3 and was intubated.

Course...1 st DOL MV settings of Fi02 30%, RR 40, PIP/PEEP 16/4, IT 0.4. Patient was put to NPO, IVF D 10 IMBCa 300 was started. Patient became stable with O2 sats of 95%. Cranial CT scan plain and with contrast was requested. On Duty rounds, noted eye opening and withdraws to pain. Feeding was then resumed (42 cc/kg/day).

Course...2 nd DOL On the 2 nd day of life, feeding was increased. Weaning was started until FiO2 of 21%. Medications continued and serial ABGs done. Seen by NSS, agreed with CT scan. At 3pm, referred for coffee ground material. Patient was then put to NPO. Famotidine (0.5) & Vitamin K 1mg started. FFP 50cc/alliquot was then ordered for transfusion.

Course...2 nd DOL Assessment at that time was Central Apnea. On Duty rounds, serial ABGs done. Pentoxitylline was started. MV settings: FiO1 21%, PIP/PEEP 16/4, RR 40, IT 0.4. Plan is to wean RR by 2 q2 until 30.

LABS CBC12/19: Hgb 151, hct 0.435, wbc 9.58, plt 209, neut 0.470, lympho CHEM12/20: Ca 2.226, Na 131, K 4.7, Cl 99 12/21: BUN 3.40, Crea 79, Ca 2.25, Na 131, K 3.7, Cl 97 12/22: Na 135, K 4.0, Cl 102 CSF12/23: Glu 3.01, CHON 0.98 Q/Q: pale yellow, clear, rbc 110, wbc 0 ABG12/21: (30%, 16/4, 40, 0.4) 7.354/37.7/132.8/21.0/-3.6/98.4% 12/21: (30%, 16/4, 40, 0.4) 7.365/39.0/162.1/22.3/-2.3/99% 12/22: (21%, 16/4, 30, 0.4) 7.421/40.6/76.1/26.4/2.4/95.4% 12/23: (21%, 16/4, 30, 0.4) 7.617/26.6/147.8/27.1/8.3/99.3% 12/24: (21%, 16/4, 30, 0.4) 7.384/50.6/110/30.2/4.4/97.8% Blood CS12/20: NG2D