Marissa A. Resulta, M.D.

 M.G., newborn, male  preterm from a 34 year old G1P0  Outlet forceps extraction sec to preeclampsia  8 th hr of life, (+) swelling on the right scalp  Admitted to NICU 2.

 Awake, crying, fair activity  HR: 160 RR 40 T 36.5 C Wt: 1850 grams HC: 31 cm CC: 25cm AC: 22cm L: 46cm  (+) caput occipitoparietal, right (+) abrasion mid occiput, anterior fontanelle soft & flat  Symmetrical chest expansion, no retractions, clear breath sounds, no crackles, no wheezes  Adynamic precordium, distinct heart sounds, normal regular rhythm, no murmur  Soft abdomen, no organomegaly  Full & equal pulses, no fractures

 S: (+) pallor (+) jaundice  O: asleep, arousable  HR: 162 RR: 50 T 36.5  (+) scalp swelling right, occiput  A: Anemia secondary to acute blood loss  P: Dxtics: Cranial CT scan, CBC, ABG, PT/PTT, BT TFI- 80- increased to 120, given 40cc/kg) PNSS  Hook to O2 at 0.5 lpm NC  BT of pRBC (15cc/kg) & FFP  Vitamin K (1)  Dopamine (5) – (8)

 Cranial CT scan: diffuse extracalvarial soft tissue swelling with note of hyperdensities (hematoma) in the right high parietal region.  ABG: 7.405/ 26.3/ 125.3/ 16.4/ -6.2/ 98.4%  CBC:67/0.225/8.27/0.67/ 0.18/ 0.11/ 0.01/ 123  PBS: mod hypochromia, mod anisocytosis, marked poikilocytosis, (-) toxic granulation  PT/PTT: 12.6/ 17.2/ 0.45/ 1.56  34.9/ 60.7  Blood type O+

 Preterm, 34 weeks by pediatric aging, 1850 grams, appropriate for gestational age, cephalic, delivered via outlet forceps extraction secondary to severe preeclampsia, live baby boy apgar 3, 7 Subgaleal hematoma

 S: D6 (+) apnea (+) cyanosis (+) bradycardia  O: HR: 160s  (+) milk/ orem & OGT  Clear breath sounds, (-) retractions  A: Aspiration pneumonia r/o nosocomial sepsis  P: Dxtics: CBC, Blood CS, babygram  Hook to 2 NCPAP 40% PEEP 5  Meropenem (40)  Amikacin (15)  Pentoxifylline  Dopa (5)- Dobu (5)

 S/O: 1 st week of life: (+) jaundice  Total Bilirubin:  PT/PTT: 12.6/ 17.2/ 0.45/ 1.56/ 34.9/ 60.7  A: Hyperbilirubinemia sec to subgaleal hematoma  P: BT pRBC & FFP  phototherapy  Difficulty in IV insertion- UAC  Umbilical vein catheterization x2 weeks

 S: 11 th DOL: (+) grade 3/6 holosystolic murmur  O: HR: 168 RR 60 T 37.8 C  2D echo: oscillating mass attached to the tricuspid valve measuring 3.5cm in diameter. No pericardial effusion. Good biventricular contractility.  A: Infective endocarditis (iatrogenic)  P: Remove UVC  Dxtics: Blood CS x 2sites-(+)yeast cells after 1.5hrs  ESR, CRP, CXR APL  Txtics: Meropenem (40)  Vancomycin (40)- (60)  Fluconazole (12) – (6) to Ampho B

 5/12: Large vegetation attached to the tricuspid valve at the right atrium measuring 2x1.3cm. Mild tricuspid regurgitation.  40 th DOL: intubated ET 3.5 L8  Inotropes Dopa & Dobu  5/17: Infective endocarditis at the right atrium measuring 2.5/1.6 cm with mild TR & TS.

 Referred for HR: 0  (+) fresh blood/ OGT, ET  Code called  Given Epinephrine per ET/ OGT  Inotropes Dopa10-20, Dobu 10-20, Epi 1  Given total of 65cc/kg PNSS & 2meqs NaHCO3  Patient never revived.

 Disseminated intravascular coagulopathy secondary to septic emboli (sec to umbilical catheterization)

 Diffuse alveolar damage secondary to pneumonia  Fungal endocarditis (Candida albicans) secondary to umbilical catheterization  Septic embolism

 4/26: (+) Candida sp after 1.52 hrs (+) yeast cells  5/4: (+) Candida sp after 1.16 hrs  5/11: (+) Candida albicans after 2 hrs  5/20: GS: (+) for gram (-) bacilli CS: (+) Klebsiella pneumoniae after 3 hrs Sensitive: Amikacin, Ertapenem, Meropenem Intermediate: Ciprofloxacin Resistant: Amoxi-Clav, Ampi, Ampi-Sul, Aztreonam, Cefoxitin, Cefepime, Ceftazidime, Ceftriaxone, Cefuroxime, Gentamicin, Trimethoprim

4/7/11 4/8/114/13/114/16/114/20/11 WBC Hb Hct Plt Retic0.083 Neut Lympho Mono Eos Baso Stab Meta Myelo nRBC42347 sp pRBCSp pRBC

4/28/115/5/11 5/145/18/11 WBC Hb Hct Plt Neut Lympho Mono Eos Baso Stab Meta Myelo Promyelo0.02 nRBC sp pRBCs/p PCsp pRBC