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Original Question
Make a pathology for this case scenario- Infant of drug dependent mother CASE: Baby LV with a birth weight of 2kg was born to a 18 years old mother with a history of alcohol and drug dependence via NSD. Initial APGAR score at 1minute is 6 (resuscitation was done) and 8 at 5 minutes. Ballard scoring was done with a maturity score of 25. The baby was admitted (4-22-22) in the primary NICU for observation and management under the service of Dr. Santos. DOCTOR’S ORDER: TIME SIDE NOTES DOCTOR’S ORDER 6:30 am 10:15 am 12:25 pm Weight- 2 kg Ballards score- 25 Oxygen sat at room air- 92-94% Mother claims to have drug and alcohol intake 3 days (” I am wasted”) prior to delivery (+) tachypnea CBG- 38mg/dl irritable Admit to primary NICU under my service. Thermoregulate the patient at all times VS q2 I&O qshift WOF: irritability, tachypnea, sleep disturbance, vomiting, diarrhea and tremors Hook to oxygen at 3-5lpm via oxygen hood Start D10W at 100ml/kg/day For CBC, babygram, ABG Start feeding with 300 kcal/day via OGT q3-4 hours. Assess sucking reflex and swallowing reflex. Relay lab result once available Refer accordingly. Dr. Ramos Administer 8ml IV bolus of D10W Suggest to start Phenobarbital 6mg IV q8 hours Dr. Perez (Resident Neonatologist) Carry out orders of Dr. Perez re Phenobarbital Start Ampicillin 75 mg IV q8 Gentamicin 27 mg IV q12 hours For urine and meconium sampling (drug and alcohol testing) Nurses Notes: IVF started at 6:30am at right basilic vein OGT inserted at 6:45 am, feeding started at 7am. Patient was hooked to oxygen at 3-5 lpm via oxygen hood and was placed on a prone side lying position. Thermoregulated under a radiant warmer. excessive sucking and rooting reflex was noted. CBC: Hgb- 19.5 Hct- 67% RBC- 8 ABG PH- 7.54 PCO2- 29 HCO3-22 Babygram: patchy infiltrates in L lower lung fields Vital signs: 8AM 10AM 12PM 2PM TEMP 36.7 36.4 36.8 37 HR 153 147 152 146 RR 38 64 52 61 URINE +(9AM) 1DC STOOL +Meconium (1:30 pm)
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