H&P:
Identifying Data:
Full Name: Mr. C. R-J.
Address: 11-64 186th street Queens, NY
DOB: 10/06/2020
Date & Time: October 6th 2020 at 1000
Location: NICU
Religion: Unknown
Source of Information: Mother
Source of Referral: Mother
Mode of Transport: Mother
CC: premature baby with abnormal breathing
HPI:
1 day old Hispanic female brong 2627g at gestational age of 37 w3d called to attend delivery due to maternal on magnesium sulfate. Live female delived NSVD cried immediately after birth within 2 minutes baby was grunting and nasal flaring and high respirations. .
Maternal blood type O positive
Hepatitis B negative,
HIV negative ,
Rubella immune,
GBS cervix {negative,
RPR negative,
Chlamydia negative, Gonorrhea negative,
PPD unknown,
Quantiferon negative,
COVID19 negative (10/6/20)
Visit Vitals
| BP | 69/44 (Left leg) |
| Pulse | 130 |
| Temp | 97.7 °F (36.5 °C) (Axillary) |
| Resp | 55 |
| Ht | (!) 7.48″ (19 cm) |
| Wt | 5 lb 12.7 oz (2.627 kg) |
| HC | 32 cm (12.6″) |
| SpO2 | 100% |
| BMI | 72.77 kg/m² |
| BSA | 0.09 m² |
Review of Systems:
Unable to obtain
Allergies: No Known Allergies
Medication:
None
Pregnancy complications: Chronic HTN, pre-eclampsia
PMH: Magnesiums sulfate maternal
APGAR 1min 9/10 5 min 9/10
Physical Exam:
Normal Female Exam
| General Appearance | Healthy-appearing, vigorous infant, strong cry |
| Head | Sutures mobile, fontanelles normal size |
| Eyes | Sclerae white, pupils equal and reactive |
| Ears | Well-positioned, well-formed pinnae |
| Nose | Clear, normal mucosa |
| Throat | Lips, tongue and mucosa are pink, moist and intact; palate intact |
| Neck | Supple, symmetrical |
| Chest | Lungs clear to auscultation, grunting, use of accessory muscles |
| Heart | Regular rate & rhythm, S1 S2 |
| Abdomen | Soft, non-tender, no masses, no organomegaly ; umbilical stump clamp and three vessel cord |
| Pulses | Strong equal femoral pulses |
| Hips | Negative Barlow, Ortolani |
| GU | Normal female genitalia |
| Extremities | Well-perfused,warm and dry |
| Neuro | Easily aroused; good symmetric tone, normal newborn reflexes, |
Preliminary Ddx:
RDS,
sepsis,
hyaline membrane disease
Lab Results: CBC
- WBC 30.25
- RBC 3.65
- HGB:13.9
- HCT: 38.7
- MCV: 106.4
- MCH: 38.9
- RDW: 15.2
- PLT: 193
- Diff: neutrophil79.7
FINDINGS:
Lungs: Bilateral perihilar haziness. Patchy opacities at the lung bases with
suggestion of bronchograms, cannot rule out multifocal pneumonia.
Pleural space: Poor visualization of the costophrenic angles, cannot rule out
pleural effusions.
Heart/Mediastinum: Unremarkable. Cardiothymic silhouette is within normal
limits. Visualized airway is unremarkable.
Bones/joints: Unremarkable.
IMPRESSION:
IMPRESSION:
Bilateral opacities, cannot rule out airspace disease in an appropriate
clinical context.
Assessment/Plan
Respiratory:
On HFNC 3L/min 25% FiO2
Respiratory Distress due to perinatal magnesium
Chest and Abdomen X-ray obtained- results pending
Arterial Blood Gas Obtained- showed no acidosis.
Chest X ray Showed no PTX – TTN Pattern.
Monitor for respiratory distress
Titrate FiO2 to maintain saturations 92%-96%
Infection:
Elevated neutrophil count
Plan: Start genatmycin and ampicillin
Obtain blood culture
Cardiovascular:
Hemodynamically stable
Plan:
Monitor clinically
Echo as needed
Hematology:
Blood type: Mother O positive, Baby pending Coombs pending
CBC and Cord Blood sent to lab
Plan:
Follow-up labs
For AM Bilirubin level
Metabolic:
Magnesemium level pending
Initial blood sugar 86 mg/dL
Plan:
Follow-up Magnesium level
Follow and Trend Blood Sugar Levels
Consider D10W bolus as needed
Neurological:
Normal exam
Plan:
Monitor clinically
Gastroenterology:
Abdomen soft, non-distended
(+) bowel sounds
Due to void and stool
Plan:
Monitor intake and output
Nutrition:
NPO
Plan:
Opthalmology:
No issues
Endocrine/Genetics:
No issues
Social:
Pending Social clearance
Plan:
Update Parents regarding plan of care and support
Encourage breastfeeding, breast milk expression and bonding
Typhon Report:
Article Review:
One of the patients I managed during this rotation had Down syndrome and she was being evaluated for low hemoglobin and other abnormal laboratory levels within her CBC. It turned out that she may have some form of blood cancer. Down syndrome children are more likely to have leukemia along with other disorders throughout life. This articles describes to correlation between Down Syndrome and leukemia and addresses the specific gene that is involved. The article continues to mention that conventional treatment for leukemia does not fair well for the patient and often leads to other toxic complications. Nevertheless it is noteworthy to address the fact that Down Syndrome patients often have better outcomes and are more likely to have fewer long term side effects from leukemia.
Site Evaluation Summary:
The site evaluation was quite informative and very helpful in preparing a clinical pediatric note. The site evaluator really focused on the drug cards and providing important suggestions on use and side effects of medications. For the majority of the time it was more of a conversation which was more comfortable. In addition, the evaluator did not hesitate in asking us follow up questions and other important topics to see what we as students knew. Listening to other students present and provide feedback was extremely helpful and it gave a better understanding of how diverse clinical note taking can be.
Summary:
The pediatric rotation was a great learning experience. The first 2 weeks of the rotation was at the pediatric emergency room and there was a wide variety of patients that presented. The providers that I worked under really focused on stabilizing the patient and instructing them to follow up with their primary care physician. The patients that presented to the ER ranged from a couple of weeks old to up to 21 years old and their conditions ranged from ankle sprain to possible leukemia. The ER setting was very hands on and I was able to perform a multitude of procedures.
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