1. Enero, Marian 48 days old/ F Date of Birth: 5/10/14 Date of Admission: 5/15/14 Hospital Stay: 41 days

2. CHIEF COMPLAINT PREMATURITY

3. HISTORY OF PRESENT ILLNESS MATERNAL HISTORY > 32-year old, G3P3 (2103) > Check up: Delgado Hospital; 1 month AOG; OBGYNE > 2 months AOG – diagnosed with Hypothyroidism; L- thyroxine until delivery > 3 mos AOG – vaginal spotting; Duvadilan; bed rest > 3 rd trimester – UTI; Cefuroxime for 7 days > Ultrasound – twice; unrecalled AOG – placenta previa marignalis

4. HISTORY OF PRESENT ILLNESS MATERNAL HISTORY > 2 weeks prior to delivery – vaginal bleeding, no contractions; Delgado Hospital x 1 day; IE – close cervix; tocolytic given; bed rest > 1 week prior to delivery – with contractions & vaginal bleeding; Delgado hospital x 1 week; MgSO4 & other unrecalled medications; transferred to St. Luke’s Medical Center 1 day prior to delivery

5. HISTORY OF PRESENT ILLNESS MATERNAL HISTORY  St Luke’s Medical Center - vaginal bleeding; Bricanyl drip, Ampicillin, Gentamicin; UTZ – low lying placenta; with decelerations hence delivered

6. HISTORY OF PRESENT ILLNESS BIRTH HISTORY  St Luke’s Medical Center SIGN0121 MIN5 MIN COLORBlueAcrocyan otic Pink0Tactile stimulation 1 HEART RATEAbsent<100>1002PPV2 REFLEXNo response GrimaceCry/active withdrawa l 1Gentle suctioning 2 MUSCLE TONE LimpSome Flexion Active Motion 0Intubated at 3 mins 1 RESPIRATIONAbsentWeak cry; hypoventi lation Good crying 11 TOTAL47

7. HISTORY OF PRESENT ILLNESS BIRTH HISTORY  St Luke’s Medical Center - No cord coil, MSAF - BW – 794 g; BL – 32cm; HC – 21.5; CC – 20; AC – 18  NICU x 5 days - NBS (5/10); Vit. K - UVC & OGT inserted - Ampicillin, Gentamicin, Cefotaxime - Aminophylline -Paracetamol 10mkdose q6 (5 doses)

8.  NICU - TPN with trophic feedings - BCS done - EXTUBATED on the 5 th hospital day  Transferred due to financial constraint  Diagnosis: Neonatal Sepsis, PDA HISTORY OF PRESENT ILLNESS

9. FAMILY HISTORY (+ ) HPN ( -) DM ( -) BA ( -) FDA ( -) PTB 3235 119

10. PROBLEMS 1. CARDIOVASCULAR 2. RESPIRATORY 3. GASTROINTESTINAL 4. RENAL 5. INFECTIOUS PATENT DUCTUS ARTERIOSUS PNEUMONIA; PNEUMOTHORAX NECROTIZING ENTEROCOLITIS ACUTE RENAL FAILURE SEPSIS, unspecified

11. CARDIOVASCULAR (+) murmur, machinery-like, best heard at parasternal L upper chest, with radiation to axilla, L, 3/6, systolic Medical closure -Paracetamol (SLMC-5 doses) - Ibuprofen not given Furosemide 0.5mkdose q12 (6 th DOL)  inc to 1mkdose q12 (7 th DOL)  revised to 0.5mkdose q8 (13 th DOL)  inc to q6 (27 th HD)  inc 1mkdose q12 (28 th HD)  inc to q8 (29 th HD)  dec (39 th HD) Captopril (0.6mkdose q12) on 33 DOL Digoxin (0.025mkdose OD) Fluid restriction (TFR-130) PDA

12. Laboratories 2D ECHO: 5/15 – PDA 0.3 cm L  R 6/9 – PDA 0.3 6/18 – PDA 0.28-0.32 cm

13. RESPIRATORY- Pneumonia (+) crackles (+) CXR with infiltrates and officially read as pneumonia -Antibiotics given NEONATAL PNEUMONIA

14. Diagnostics & Laboratories CXR 5/15 – Neonatal Pneumonia with air trapping 5/27 – mild interval decrease in bilateral pneumonic infiltrates; heart slightly enlarged 6/7 – Interval progression of bilateral pneumonic infiltrates; lung hyperinflated 6/13 – No change in bilateral pneumonic infiltrates; heart findings unchanged 6/19 – unchanged degree of cardiomegaly but with progression of pulmonary congestion and/or edema; intercurrent pneumonia considered 6/20 – interval decrease of bilateral pulmonary opacities; heart not enlarged; multiple dilated bowel loops probably ileus 6/21 – no change in caliber and pattern of bowel dilatation suggestive of distal bowel obstruction 6/21 – no significant change in the degree of bowel dilatation w/ paucity of pre- sacral gas; bilateral pneumonic infiltrates 6/21 – massive right sided pneumothorax w/ inversion of the right hemidiaphragm and contralateral mediastinal shift 6/21 – post right chest tube insertion shows re-expansion of the right lung with significant decrease in pneumothorax; increase opacification of both lungs likely due to progression of pneumonia; true cardiac size can’t be assessed 6/24 – regression of R pneumothorax; unchange pneumonic infitrates more on the R

15. RESPIRATORY- Pneumothorax (+) Desaturations and decreased breath sounds on the 46 th DOL Set up: Fio2 – 30 RR – 10 PIP – 14 PEEP - 5 -Needling -CTT inserted PNEUMOTHORAX

16. GASTROINTESTINAL (+) Coffee-ground/ OGT – 6 th DOL (1 st HD) (+) 18 th DOL - abdominal distention - hypoactive BS (+) 30 TH dol - abdominal distention - coffee ground/ogt -NPO -Trophic Feeding -Famotidine -Metronidazole NEC STAGE 1

17. RENAL (+) Oliguria on 41 st DOL (+) Polyuria 44 th DOL -Co-managed with Nephro -Hydrated -Dopamine -Replace UO >4cc/kg/hr ACUTE RENAL FAILURE

18. INFECTIOUS (+) increasing infiltrates on CXR (+) apnea (+) abdominal distention, coffee ground -Ampicillin, Gentamicin  Cefotaxime  piptazo  Meropenem  Vancomycin, Fluconazole  Ciprofloxacin, Metronidazole  Cefipime  Meropenem, Amikacin, Amphotericin

19. FINAL DIAGNOSIS Multiple Organ Dysfunction PT 26 wks by BS, AGA, 29-30 wks CA, Neonatal Sepsis, Pneumonia, NEC stage I PDA (0.3) AKI secondary to sepsis Hospital Acquired Infection