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Respiratory Distress Syndrome

Respiratory Distress Syndrome. Capili , Datukon , De Castro, de la Llana , Golepang. General Data. Baby Boy of Phoebe Santos NB/M From Cainta Admitted November 18, 2009. History of Present Illness. Born 27 weeks and 5 days to a 17 y/o primigravid

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Respiratory Distress Syndrome

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  1. Respiratory Distress Syndrome Capili, Datukon, De Castro, de la Llana, Golepang

  2. General Data • Baby Boy of Phoebe Santos • NB/M • From Cainta • Admitted November 18, 2009

  3. History of Present Illness • Born 27 weeks and 5 days to a 17 y/o primigravid • Cephalic presentation, delivered via SVD

  4. History of Present Illness

  5. History of Present Illness

  6. Maternal History • Mother is a 17 y/o primigravid, 4 PNCU’s c/o LHC

  7. Family Medical History • (+) HPN – mother’s side • (+) heart disease (mother) • (-) DM, PTB, BA, allergies • (-) history of kidney or liver disease

  8. Personal/Social History • Mother is 17 years old, unemployed • Father is 20 years old, unemployed

  9. Physical Examination • HR 140’s RR T 37.1oC • Awake, active, (+) jaundice, anterior fontanelle soft and flat • Equal chest expansion, (+) retractions, (+) rales over lower lung fields • (-) heaves/thrills, distinct heart sounds, (+) grade 2/6 holosystolic murmur, LPSB • soft, globular, (-) masses • Bounding pulses, pink nail beds, necrotic first digit of LLE, (-) cyanosis/clubbing/edema

  10. Problem List • Respiratory Distress Syndrome • Intubated ET 2.5 L 7 • Multiple episodes of cyanosis and desaturation • (+) rales on bilateral lower lung fields • (+) retractions • Cardiac: t/c PDA • Grade 2 Holosystolic murmur, best heard on LPSB; bounding pulses • Referred to Pedia Cardio for 2D Echo • Currently on Ibuprofen for medical closure

  11. Problem List • Infectious: t/c sepsis • Awaiting final blood CS results • Meropenem, amikacin • Vitamin K, FFP • Vascular: necrotic 1st digit of LLE • Referred to TCVS, awaiting entries • Hyperbilirubinemiaprob 2o to sepsis • CPT • Monitoring of TB DB IB

  12. Present Working Impression • Pre Term 28 weeks by Pediatric Aging, 800g, appropriate for gestational age, cephalic presentation delivered via spontaneous vaginal delivery, live baby boy, APGAR 9, 9 • Respiratory distress syndrome (HMD) • Hyperbilirubinemia probably 2o to sepsis • r/o sepsis • t/c PDA • Necrotic first digit of L lower extremity

  13. Current Medications

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