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NICU AUDIT

NICU AUDIT. February 2014. JPB. Born on February 14, 2014 Live preterm baby girl Delivered via Scheduled Primary Cesarean Section for Maternal Condition (Breast Cancer) 41 y/o G2P2 (1102) 2 8 5/7 weeks AOG. BW 1250 g BL 38 cm HC 26 cm CC 23 cm AC 21 cm MT 30, AGA AS 9,9.

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NICU AUDIT

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  1. NICU AUDIT February 2014

  2. JPB • Born on February 14, 2014 • Live preterm baby girl • Delivered via Scheduled Primary Cesarean Section for Maternal Condition (Breast Cancer) • 41 y/o • G2P2 (1102) • 28 5/7 weeks AOG • BW 1250 g • BL 38 cm • HC 26 cm • CC 23 cm • AC 21 cm • MT 30, AGA • AS 9,9

  3. Maternal History • Chronic hypertensive for 24 years, usual BP 140-150 systolic • Feb 11, 2014- admitted at IMU for increase in BP given Methyldopa and Dexamethasone 10 mg every 12 hrs for 2 doses

  4. Past Medical History • Feb. 2013 • noted to have a 2x3 cm mass on the left breast. • Mammography done showing “malignancy” but was lost to ff- up • Feb. 3, 2014 • Breast mass was increasing in size w/ engorgement of the breast • Biopsy done w/c showed Intraductal Carcinoma of the Left Breast, BIRADS 4 • Feb 12, 2014 • Ultrasound done: BPS 8/8, EFW 1305 g, Placenta anterior, grade 2, high lying, normohydramnios, Myoma 2.5X2.6 cm

  5. Family History • DM • HTN Personal/ Social History • unremarkable OB History • G1- 2008, NSD, Full Term, male, BW 8lbs • G2- present pregnancy

  6. Delivery • Apgar 1 min: HR >120’s, acrocyanotic, good cry and activity, spontaneous breathing • Apgar 5 min: HR >120’s, acrocyanotic, good cry and activity, spontaneous breathing • Immediately placed in a food grade plastic bag • O2 saturation: >85% • Newborn care was rendered

  7. 2nd Hour of life

  8. 1st day of life

  9. 4th day of life

  10. 5th day of life

  11. 7th day of life

  12. CBC, hgt, chest xray

  13. 14th day of life

  14. CBC, hgt, chest xray

  15. 15th day of life

  16. 16th day of life

  17. Current Diagnosis Prematurity, Very Low Birth Weight, Apnea of Prematurity, Sepsis, Mild Respiratory Distress Syndrome, Hyperbilirubinemia, unspecified, Resolved

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