DATE OF SERVICE: MM/DD/YYYY
CHIEF COMPLAINT: Maternal chorioamnionitis.
MATERNAL HISTORY: The patient is a (XX)-year-old gravida 1, para 0 Asian woman who did receive prenatal care. Her labs include O positive blood type, antibody negative, hep B surface antigen negative, rubella immune, VDRL nonreactive, GBS negative, and herpes denies. She has a history of asthma. She was admitted with contractions. Her EDC was (XX). She received antibiotics less than 4 hours prior to delivery.
DELIVERY SUMMARY: Baby boy is a 3430 g product of a 40 plus 3-week gestation pregnancy, born by primary C-section. Anesthesia was epidural. Artificial rupture of membranes occurred 12 hours prior to delivery. There was thin meconium. The infant was in vertex presentation. There was a nuchal cord, which was easily reduced. The infant was vigorous with a good tone and cry. Apgars were 8 and 9 at one and five minutes respectively. He was dried, stimulated, and suctioned. He was allowed to bond with the mother and then transferred to the NICU per chorio protocol.
PHYSICAL EXAMINATION:
VITAL SIGNS: Heart rate is 150, respiratory rate 48, temperature 37.2 degrees Celsius, blood pressure 76/38 with a mean of 50, saturations 96% on room air. Weight is 3430 g, length 49 cm, FOC 36 cm, making him AGA.
HEENT: Anterior fontanelle is soft and flat. Sutures are approximating. There is some mild head molding. Eyes: Pupils are equal and reactive to light with red reflexes bilaterally. Mucous membranes of the mouth and nose are pink and moist. The palate is intact.
NECK: Soft with good range of motion. No masses are felt. Clavicles appear intact.
CHEST: He has clear and equal breath sounds with good air entry bilaterally.
HEART: He has a regular rate and rhythm. No murmur is heard. Capillary refill time is less than 3 seconds, and he has good pulses in all 4 extremities.
ABDOMEN: Soft and nondistended with active bowel sounds.
GENITOURINARY: He has a 3-vessel cord, which is clamped. Normal male genitalia. Testes are descended bilaterally, and the anus is patent.
BACK: Straight with no tufts or dimples.
EXTREMITIES: Grossly normal. No hip clicks are noted.
SKIN: Pink, warm, and intact.
IMPRESSION: This is a term male with rule out sepsis related to maternal chorioamnionitis.
PLAN:
1. We will allow infant to breast-feed ad lib on demand. Follow labs in the morning.
2. Obtain blood culture and CBC now. Begin ampicillin and cefotaxime and follow CBC and CRP in the morning.
3. Update the family. The father of the baby was updated at the bedside. We discussed the plan for antibiotics for a minimum of 48 hours and up to a week if the infant is clinically septic. We will continue to update them through the course of the infant’s stay.
