ATTENDING NEONATOLOGIST: Dr. John Doe
PEDIATRICIAN: Dr. Jane Doe
OBSTETRICIAN: Dr. Jeff Doe
CHIEF COMPLAINT: Prematurity, 35-week twin gestation, RDS.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old gravida 2, para 1, full term 1, living 1, mother who presented with contractions and leg swelling. Her EDC was MM/DD/YYYY. She received prenatal care with Dr. (XX) for monochorionic diamniotic twin gestation. A primary C-section was done for maternal ITP. Twin B was footling breech and velamentous cord. The mother received spinal anesthesia. AROM was clear at delivery. Maternal blood type is O positive. The antibody screen is negative. HIV negative. Hep B negative. RPR nonreactive. She denies HSV. She is rubella immune. GBS unknown. Positive PPD with negative chest x-ray. Baby girl (XX) twin B was received by the ALS team, noted to have cyanosis with grunting and retracting. Please see ALS note. The infant was admitted to the NICU, placed on nasal CPAP of plus 5 and weaned to 25% FiO2. UAC and UVC catheter were placed by the ALS RN. Birth weight 2635 g, head circumference 39.5 cm, length 47.5 cm. Glucose was 42 and the followup was 51.
ADMISSION VITAL SIGNS: Axillary temp 36.1, heart rate 170, respiratory rate 60, BP was 46/40 with a mean of 44.
PHYSICAL EXAMINATION:
HEAD, EYES, EARS, NOSE, AND THROAT: Anterior fontanelle is soft and flat. Bilateral red reflex is seen. Palate is intact. Nares appear patent. Ears are grossly normal.
CARDIOVASCULAR: Heart rate is regular rate and rhythm with no murmur audible. Pulses are 2+ and equal in 4 extremities. Cap refill is 2 to 3 seconds. The infant is noted to be plethoric.
RESPIRATORY: Bilateral breath sounds are equal and coarse. Substernal retractions on nasal CPAP are noted.
GASTROINTESTINAL: Abdomen is soft, nondistended, with positive bowel sounds. There is a 3-vessel cord. No hepatosplenomegaly or masses are felt.
GENITOURINARY: Female genitalia. The anus is patent.
MUSCULOSKELETAL: The spine is intact. There are no hip clicks.
IMPRESSION:
1. A 35-week twin B female.
2. Respiratory distress syndrome (RDS).
3. Suspected sepsis.
PLAN:
1. Wean CPAP as tolerated. Obtain chest x-ray and follow up ABG.
2. CBC, blood culture on admission, AMP and CEF. Follow up CBC and CRP in a.m.
3. UAC half normal saline, 1 unit of heparin per mL at 1 mL an hour.
4. UVC 200 D10W with 200 mg of calcium gluconate per 100 and 0.5 units of heparin per mL at 8 mL an hour for total fluids of 80 mL per kilo per day.
5. BMP and bili in a.m.
6. The father of the baby was updated at the bedside on infant’s condition and plan of care.
