DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Prematurity and respiratory failure.
MATERNAL HISTORY: Mom is a (XX)-year-old gravida 3, para 2-0-0-2 Asian woman who did receive prenatal care. Her labs include A positive blood type, antibody negative, hep B surface antigen negative, rubella immune, VDRL nonreactive, GBS unknown and herpes denies.
She received steroids x2 doses. She received antibiotics less than 4 hours prior to delivery. The pregnancy was complicated by advanced maternal age, morbid obesity, prolonged premature rupture of membranes for about three weeks and placental abruption. She was admitted for spontaneous rupture of membranes and has been in the PSCU. Her EDC is MM/DD/YYYY. Decision was made to C-section today for abruption and breech presentation.
DELIVERY SUMMARY: The baby is a 1264 gram product of a 28 plus 1 week gestation pregnancy born MM/DD/YYYY at XXXX a.m. by C-section. Anesthesia was spinal. Spontaneous rupture of membranes occurred on MM/DD/YYYY, which was about three weeks ago. Fluid was clear/bloody. Apgars were 5, 4, 6 and 7 at one, five, ten and fifteen minutes respectively.
The infant came out with a small cry, was active, but had very poor air entry, tight breath sounds and minimal respiratory effort. Saturations were in the 40s. CPAP was begun. Shortly thereafter, positive pressure ventilation was begun secondary to minimal respiratory effort and low saturations. FiO2 was increased gradually to 100%.
At 4 minutes of life, he was intubated and bag mask ventilation was continued. Sats were slowly increasing. He was given surfactant at about 14 minutes of life and his saturations then increased into the 90s. FiO2 was slowly weaned down to 60%, and he was transferred to the NICU on the Neopuff. See the delivery summary for more detailed account of baby’s resuscitation.
PHYSICAL EXAMINATION:
VITAL SIGNS: Heart rate is 178, respiratory rate is undeterminable as he is on high-frequency ventilation, temperature is 37.4 degrees Celsius, blood pressure 60/32 with a mean of 43, saturations 94% on 65% oxygen. Weight is 1264 grams, length 37.4 cm, FOC 26 cm, all of which are around the 50th percentile.
HEENT: Anterior fontanelle soft and flat. Sutures are approximating. Pupils are equal and reactive to light with red reflexes bilaterally. Mucous membranes of the mouth and nose are pink and moist. He is intubated.
NECK: Soft with good range of motion. Clavicles are intact.
CHEST: He has very tight breath sounds. Fair air entry. Mild subcostal and intercostal retractions and now with good bounce on high-frequency ventilation.
HEART: He has a regular rate and rhythm. No murmur is heard. Cap refill time of 3 seconds and good pulses in all four extremities.
ABDOMEN: Soft and nondistended with hypoactive bowel sounds.
GENITOURINARY: He has a 3-vessel cord.
GENITALIA: Normal male genitalia. Testes are in the canal bilaterally. Anus is patent.
EXTREMITIES: Grossly normal. There is breech positioning of the legs.
BACK: Straight with no tufts or dimples.
SKIN: Pink and intact.
LABORATORY DATA: Glucose of 65. ABG, the pH is 7.26, pCO2 of 52, pO2 of 60, HCO3 of 22 and base deficit of -6.
IMPRESSION: This is a (XX) plus (X) week gestation male with respiratory distress syndrome, rule out sepsis and hypoplastic lungs.
PLAN:
1. N.p.o. We will place the UAC and UVC. We will begin total parenteral nutrition and follow labs in the morning.
2. We will continue high-frequency oscillatory ventilation. Obtain ABGs every one to two hours. Obtain a chest x-ray. Once the lines are placed, he may need a second dose of surfactant.
3. Obtain a blood culture and CBC now. Begin ampicillin and cefotaxime. Follow CBC, CRP in the morning and send a tracheal aspirate.
4. Head ultrasound in the morning.
5. Nutrition consult.
6. We will update the family. The father of the baby was updated. We will continue to update him and the mother while the infant is here in the NICU.
