C.

B
NB
 Maternal History:
E.B. was born to a G4P4 36yo mother via NSD at SPMC, with APGAR score of 1,3,3 Ballards score of 39
weeks, birth weight 3.129kg, Appropriate for gestational age
Prenatal Labs:
Maternal Diagnoses, procedures during pregnancy, labor and delivery:
Prenatal history:
care done x4 visit, TT given
Thickly meconium stained amniotic fluid
Non-institutional labor

DELIVERY
Delivery analgesia used: epidural. The respiratory effort at birth was spontaneous. Delivery outcome:
live birth admitted to ICN. Cord Blood Gases: ART pH=7.232 pCO2=57 pO2=10 BE=-5 VEN pH=7.28
pCO2=53 pO2=12 BE=-3 called for prematurity. Cried spontaneously. Needed blow by O2 for color and
then a few BM breaths for poor resp. effort. HR good through out. Abruption confirmed after delivery
ADMISSION HISTORY
brought over on Mask O2. First gas with pH of 7.27, CO2 60. CPAP just started. CBC,
BC sent. UAC placed and adjusted. Amp and Gent started. Hct 49.

ADMISSION EXAMINATION
GENERAL: Weight (g): 1411 (3 lbs, 2 oz) Length (cm): 39.5 Head circ (cm): 27.5 GA
Exam: 29 1/7 wks AGA
immature infant, exam consistent with dates, on CPAP
SKIN: no icterus or rashes
HEAD: open, flat anterior fontanelle
EYES: normal shape and size, equal red reflexes
EARS: immature cartilage, normally set, no anomalies
NOSE & MOUTH: nares appear patent, intact palate
NECK & CLAVICLES: no masses, clavicles intact
LUNGS & CHEST: fair air motion bilaterally
CARDIAC: normal rate and rhythm, no murmurs, pulses equal in all 4 extremities
ABDOMEN & CORD: no hepatomegaly, 3 vessel cord
GENITALIA: immature external genitalia
BACK & SPINE: straight spine LIMBS & HIPS: symmetric, moves all 4 limbs, 10 fingers
and toes NEUROLOGIC: appropriate strength and tone for gestational age
 LABORATORY RESULTS
CBC 1/05/17 CBC 1/08/17 CBC 1/09/17
1/05/17
Serum Magnesium Hemoglobin L 105.0 Magnesium 0.97
HGB 134 0.82 mmol/L g/L Hematocrit L 0.34 Sodium H 153.57
HCT .38 RBC Count L mmol/L Calcium 1.79
Sodium 139.51
RBC 3.66 2.90 mmol/L Potassium
mmol/L Potassium H
WBC 26 4.79 mmol/L
6.46 mmol/L* WBC Count H 23.91
SEG 74 Calcium 2.13 mmol/L Differential Count Sodium H 151.75
LYMP 14 Neutrophil 75 mmol/L Magnesium H
MONO 10 Lymphocytes L 14 1.24 mmol/L
PLT 317 1/07/17 Potassium H 5.15
Monocytes 10
PT Patient 15.1 Creatinine H 142.3 Eosinophil 1.000 mmol/L Calcium 2.02
Seconds PT Inr 1.21 Basophil 0 mmol/L
PT % Activity 74.0 % Potassium 4.18 Platelet Count 153
PT Control 14.6
Seconds APTT H 57.6
LABORATORY
Hemoglobin L 77.0 g/L
*VERIFIED SAMPLEAND
REMEASURED Hematocrit L
0.23 RBC
Count L 2.12
WBC Count H 13.10
Differential Count
Neutrophil 73
Lymphocytes L 17
Monocytes 10
Eosinophil L 0
Basophil 0
Platelet Count L 139
1 HD
st
S O A P
Referred dt HR: 50bpm Neonatal Meds
bradycardia RR: MV asphyxia; Cefotaxime D1
T:36.5 C Meconium Amikacin-D1
Wt: 3.129kg Aspiration Dopamine drip started (10)
O2 sat 98% Syndrome;
Neonatal Sepsis Labs:
Cranial UTZ
GCS 6 (E4V1M1) APT test
(+) coffee ground
output per OGT
Crackles BLF,
(+)spontaneous
breathing
2 nd
HD 3 HD rd

S O A P
HR: 150bpm Neonatal Aminosteril drip started
RR: MV asphyxia; Meds:
Temp: 37 C Meconium Cefotaxime D3
O2 sat: 96-98% Aspiration Amikacin D3
Syndrome; Cont. Dopamine drip
Neonatal
Sepsis,
Bradycardia HR 40-50bpm pneumonia CPR
Epinephrine 0.3cc IV x 3
doses

Epinephrine drip started (0.3)

PNSS IV bolus given
3rd HD
S O A P
Referred HR 0 Septic Shock, Neonatal CPR
arrested No Sepsis; Neonatal Epinephrine given
spontaneous asphyxia secondary to Hooked back to CAB
breathing Meconium Aspiration Pnss IV bolus
Syndrome NaHCO3 slow IV given
Pronounced dead
FINAL DIAGNOSIS