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General Data

General Data. Baby L. Male Preterm 23 2/7 AOG Delivered via scheduled NSD to a 32 year old G1P1 (0101 ) September 16, 2013 ( 12:31 pm) . Prenatal History . 1 st trimester-Urinary tract Infection treated with antibiotics x 7 days

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General Data

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  1. General Data • Baby L. • Male • Preterm 23 2/7 AOG • Delivered via scheduled NSD to a 32 year old G1P1 (0101) • September 16, 2013 (12:31 pm)

  2. Prenatal History • 1st trimester-Urinary tract Infection treated with antibiotics x 7 days • 19-20 weeks AOG, had preterm labor admitted for 5 days ( Aug 22-27, 2013) sent home on Isoxuprine • s/p Dexamethasone x 2 doses

  3. Past Medical History • 2005, diagnosed of PCOS on OCP • Primary Infertility treated with Clomiphene • 2010, 2011, 2012- s/p D&C for thickened endometrium Family History • Diabetes

  4. 24 3 minute 5 minute 10 minute 15 minute 1 1 1 1 2 2 2 1 1 2 0 2 1 2 0 2 1 1 2 1 3 6 8 9 3 5 10 15

  5. Physical Examination Vital signs: CR: 110 bpm RR: 31 cpm Temp: 34.5 Anthropometrics: • Weight: 635 g • Birth length: 31 cm • Head circumference: 22 cm • Chest circumference: 19 cm • Abdominal circumference: 18 cm Appropriate for Gestational Age

  6. MT= 24 AOG

  7. Physical Examination • SKIN: gelatinous red, translucent • HEENT: no deformity, lids are fused • CHEST/LUNGS: symmetrical chest expansion, subcostal and intercostal retractions, equal air entry • HEART: good cardiac tone • ABDOMEN: Soft, globular, umbilical stump with 2 arteries, 1 vein • GENITALIA: bilaterally undescended testis, minimal rugae • EXTREMITIES: no deformity

  8. Admitting Diagnosis Preterm Baby Boy delivered via NSD to a 32 y/o G1P1 (0101) at 23 2/7 weeks AOG; Incredibly Low Birth Weight

  9. Final Diagnosis Cardiopulmonary Arrest 2 to Bilateral Pneumothorax; Severe Respiratory Distress Syndrome; Incredibly Low Birth Weight; Extreme Prematurity

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