1. Case Discussion Sylim – Taleon Aug 18, 2009

2. Gen Data Baby girl of Melinda Balute Twin A 8 days old 8 th hospital day 7 th NICU 2 day PWI: preterm 33 weeks by PA, 1600 g, AGA, cephalic presentation via SVD, live baby girl, APGAR score 7,8

3. Birth and Maternal Hx Born to a 25-yr old G4P3 (2101) mother via NSVD at PGH-OB. Mother had 6 prenatal check-ups at PGH. Mother was diagnosed to have DTG, clin hyperthyroid (2001, DFCM) and maintained on PTU, intermittent BA. (-) vices; (-) history of infection during pregnancy

4. Course of hospital stay 8/7- patient was born (6:45 am) w/ good cry, limp, HR 140s and cyanotic. After 30 secs of resuscitation  good cry, HR 150s, limp, cyanotic  after 1 min of resuscitation w/ O2 at 10 lpm  continued resuscitation and O2 inhalation  after 5 mins, good resp effort and cry, HR 140s, acrocyanotic Transferred to NICU 3 – CBC, BT, Blood CS, babygram, electrolytes done NPO hgt, q8, IVF given was D10W @ 5cc/kg

5. At NICU 3 … Weaned FiO2 by 5% until room air Shifted to D5050 D5IMB Ca gluc 128 cc @ 5 cc/hr 11pm — started trophic feeding @3cc EBM q3 per OGT

6. 8/8: Transferred to NICU 2 –Txtics: imipinem D1 +1; amikacin D1 –Incremental feedings with IVF adjustment (TFI=90) 8/9: (+) jaundice; TB/DB/IB done  11.7 TB and IB; on CPT with shields 8/10: increase OGT feeding to 20 cc Q3; may latch on to mother 8/12: rpt TB/DB/IB done  11.03 TB and IB; feeding at 26 cc EBM + 0.4cc VCO q3/OGT (TFI=122) 8/15: increase feeding by 1 cc every feeding until 38 cc (TFI=190) + 0.6cc VCO once 38 cc is reached; for rpt TB/DB/IB

7. Fluids The patient is 34 weeks (corrected age) and currently OGT-fed with EBM and VCO. No IV line. O> OGT-inserted, good suck and activity, tolerates feeding, NABS A> may latch on and can be breastfed P> facilitate latching on to mother and start breastfeeding > cont. MV 0.3 ml, FeSO4 ).3 ml, heraclene OD > cont. VCO > weigh patient daily

8. Respiratory The patient was born limp, cyanotic, in RD, HR 140s, only became acrocyanotic after 5 mins resuscitation w/ O2 inhalation @ 10 lpm. CBC: Hgb 149, Hct 0.47, plt 273 WBC 8.94 N 0.406 L 0.48 M 0.09 E 0.019. Weaned FiO2 to room air O> RR= 46, RR= 140s afeb, (-)flaring, retraction, clear breath sounds A> TTN resolved P> WOF feeding intolerance, apnea

9. Infectious Patient was born preterm, limp, cyanotic, HR 140s afebrile; O2 requiring on 1 st day; no history of maternal infection during pregnancy. Blood CS showed no growth after 5 days incubation, normal WBC O> normal RR and HR, afeb, good suck and activity, tolerates feeding, (-) decrease in sensorium A> ruled out sepsis P> discontinue imipinem and amikacin > start breastfeeding > continue MV, FeSO4, heraclene

10. Cardiac No problem

11. Hematologic Patient is premature and prone to have anemia O> pink palp conjunctivae and skin, normal CRT A> preterm and prone to have anemia of prematurity P> cont FeSO4 and limit blood extractions

12. Metabolic the patient has normal electrolytes (Na 136 K 4.1 Cl 101 Ca 2.2) but was jaundiced on the 2 nd day of life. TB/DB/IB requested  8/9: TB 11.7 DB 0 IB 11.7 O> (+) decreased jaundice until upper trunk; BM yellowish A> indirect hyperbilirubinemia P> continue intensive phototherapy with shields > repeat TB/DB/IB > WOF fever, burns, seizure > continue feeding, facilitate breastfeeding

13. Neurologic and Developmental No problem