Good afternoon, Doctors!

 GENERAL DATA
DOB: July 10, 2022
DOA: July 13, 2022

 CC and HPI – should include gestational, birth and neonatel history sinc px is a neonate
This is a case of D.N., a 10 day-old Male from _____ who was admitted due to cyanosis.

D.N. a live baby boy born full term to a 33 y/o G1P1 (1001) mother via low-transerve CS
secondary to arrest in descent AS 5,9. Noted limp, cyanotic with poor activity at birth, mask
bagging and stimulation was done. Patient then improved and was subsequently latched with
mother.
However, on the 9th hour of life, patient had tachypnea, tachycardia and grunting, hooked to O2
NC 2 lpm, once noted with normal RR, patient was cup-fed.

On the 25th to 26th HOL, patient had cyanosis after feeding. With grunting and retractions,
patient was started on oral cefixime at 6 mkday, however, with noted persistence. On the 3 rd
DOL, patient was placed on NPO, OGT open to drain, replace volume/volume, placed on
ampicillin 100 mkday q12, and gentamicin 4 mkday OD. However, noted with cyanosis,
ambubagging was done. Patient also had episode of coffee ground per OGT. Patient was advised
transfer.

RECEIVING NOTES;
This is a case of a live baby boy born full term to a 33 yo G1P1 (1001) mother via LTCS secondary
to arrest in descent with AS 5,9, BW 2.5 kg, BS 38 weeks AGA. Prior to delivery, noted PROM fro
12 hours. PNCU done x 10 at LHC with intake of FeSO4, MVT, and Folic acid. Denies any
maternall illness. Upon delivery, mother was given epidural anesthesia. At birth, on firt minute
px was noted limp, cyanotic, with some flexion, irregular respirations, HR >100. At 5 th minute,
noted to have good activity (AS 5, 9). Patient eventually observed and was noted with no
problems. However, on the 9th HOL, noted with tachypnea and tachycardia, with grunting,
hooked to O2 via NC @ 1-2 lpm. Eventually improved, with no retractions and normal VS, hence
was started on cup feeding. At 24th HOL, O2 support eventually discontinued. During the 26 th
HOL, noted with recurrence of cyanosis upon cup feeding. Hence, advised for transfer to be
admitted at the NICU.

O> Poor activity, poor cry

VS: HR 140. RR 60, O2 sat 98%
Icteric Sclerae, PPC
SCE, (-) retractions, (-) crackles
AP NRRR (-) murmurs
Soft, nondistended abd
Fair pulses, CRT <2 secs
A> Neonatal Pneumonia; SNEO
 P> NPO for now
IVF: cont IVF (TFI 90 Dex 12.5)
D5IMB 119
D5050 39
Ca(2) 5
AA(1.5) 62
= 225 x 9 cc/hr
DX: CPC with PC, CXR APL, BTRh, ABG, BCS, HGT OD
MV settings: FiO2 100%, RR 60, PIP/FEEP 20/4; Time 0.5
TX: Give PNSS bolus 25 cc now
Ceftazidime 75 mg TIV q12 (30 mkdose)
Ampicillin 125 mg TIV q12 (100 mkday)
T/s Dopamine drip: Dopamine 0.5 cc + D5W 49.5 cc x 2 cc/hr (5)
VSq1, I&O qshift
Refer

MISSING INFO:
 REVIEW OF SYSTEMS
 PERSONAL HISTORY
o Feeding history (Infant <2)
 Immunization History
 Family History
 Socioeconomic History
 Environmental History
 PHYSICAL EXAMINATION
 GENERAL SURVEY
 VITAL SIGNS
 ANTHROPOMETRIC DATA
o Weight: 2.5 kg
o Length: 52 cm
o HC: 32 cm
o CC: 31 cm
o AC: 27 cm
 SKIN
 HEEENT
 CHEST AND LUNGS
 HEART AND VASCULAR SYSTEM
 ABDOMEN
 EXTREMITIES
 NEURO
 DIFFERENTIALS
 APPROACH TO DIAGNOSIS
 INITIAL WORKING IMPRESSION
  MANAGEMENT AND WORK UP
Diagnostics ordered:
HGT OD, CXR and CXR post intubation, BCS, RAT, ETA GSCS, ABG, VBG, PT & PTT
F TFI 150-feeding
R NCPAP FiO2 60% CA 3 O2 3 PEEP 6
Meropenem D4
Vancomycin D0

I
Ceftazidime//
Cefixime//
Ampicillin D1//
Genta D1//
C Dobutamine drip (5mkm)//
H

M
U 5.8 ckh
N OGT feeding 31cc Q3 (TFI 100)
Diazepam PRN
Phenytoin 5mkd - 3 mkday
PNSS Nebule Q4

D
Midazolam//
Vitamin K//
Furosemide//
Hydrocortisone//
NaHCO3)//

COVID RAT (07/05) Viral antigen not detected

Microscopy: Epithelial Cells +, Pus cells: +, No microorganisms seen,
ETA GSCS (7/13)
Culture: No growth after 3 days  of incubation
BCS (7/18) No growth after 5 days of incubation

7/14
ABG 7/13 7/18
4AM
pCO2 17.4 18.1 29.7
pO2 318.2 441.6 172.5
pH 7.618 7.611 7.442
HCO3 17.4 17.8 19.8
O2 99.6 99.9 99.4
sat
BE -0.9 -1.8 -3.3
TCO2 17.9 18.3 20.7

VBG 7/13

29.4
pCO2

38.8
pO2

7.263
pH

13.0
HCO3

O2 72.1
sat
-12.6
BE

13.9
TCO2

7/13

PT Control 12.1
PT 22.90
INR 1.97
% Activity 39.00
APTT 54.10

 DISCUSSION
  TREATMENT and PREVENTION

NICU

-No chief complaint; Use reason for admission

-Start with birth and maternal history

-AGE triad: edema, hematuria, hypertension

-Do complete PE and History