NICU Progress Note, Ventilator Assist

NICU Progress Note, Ventilator Assist

Dr. Ortez has been following this infant since birth.

LOCATION: Inpatient, Hospital

PATIENT: Loren Black

ATTENDING PHYSICIAN: Rolando Ortez, MD

SUBJECTIVE: Baby is currently 2 days old, slightly under 48 hours.

OBJECTIVE: Weight today is 1716 kg (decreased by 135 grams). He is down 5.1% of his weight since birth. OFC is 30 cm (decreased 0.5 cm). Intake yesterday was 152 cc, 82 cc/kg/day. Output was 170 cc, 3.8 cc/kg/hour. He has had no stools since birth. Vital signs reveal his temperature to be acceptable while on an open, radiant warmer. Heart rate is generally in the 110s-120s. Respiratory rate has generally been equal to the IMV (60). Mean blood pressures have generally been in the 40s-50s. Oxygen saturations have remained in the high 90s.

PHYSICAL EXAMINATION: In general, he is pink, on current ventilator settings. He does have slightly dysmorphic features with wide-set eyes and slightly down-slanting palpebral fissures. Ears are low set and posteriorly rotated. Endotracheal tube was in place. Neck was without masses. Chest reveals symmetric expansion and lungs are clear to auscultation on current ventilator settings. Cardiac Exam: Regular rate without murmur or click. Peripheral pulses are 2+ and symmetric. Abdominal Exam: UAC in place. Liver is palpable 1 cm below the right costal margin. No splenomegaly or masses were noted. Genital Exam: Normal male. Testes are not palpable. Extremity Exam: No fixed decreased range of motion, deformity, or joint abnormality. Neurologic Exam: Mild, diffuse hypotonia. No focal deficits are appreciated.

CURRENT MEDICATIONS

• Ampicillin 90.4 mg IV q12h.
• Gentamicin 5.4 mg IV q18h.
• Morphine sulfate 0.18 mg IV q6h and q1h p.r.n.
• Dopamine 5 mcg/kg/min.
• Vecuronium 0.18 mg IV q1-2h p.r.n.

LABORATORY STUDIES: Last arterial blood gas was obtained on ventilator setting of IMV 60, pressures of 24/4, and Fio₂ of 0.5 revealed pH 7.27, Pco₂ 51.1, Po₂ 66.5, and bicarbonate 22.5. Chemistry panel this morning reveals sodium of 134, potassium of 4.9, chloride of 102, glucose of 111, BUN of 18, creatinine of 1.0, calcium of 7.5, magnesium of 3.8, phosphorus of 7.7, bilirubin of 7.8. CBC reveals a white count of 6190. Platelet count was 98,000. Chest x-ray continues to show significant evidence of hyaline membrane disease. Endotracheal tube is near the carina and has been withdrawn somewhat.

IMPRESSION/RECOMMENDATIONS

• Two-day-old infant who was born at 30 weeks’ gestation. He does have clinical features suggestive of Noonan syndrome.
• Respiratory: Continues to show evidence of hyaline membrane disease with respiratory failure. He has received three doses of surfactant therapy. He does have echocardiographic evidence of PDA, and we will be treating this at this time. We will attempt to decrease his ventilator settings based on serial clinical examination, pulse oximetry, arterial blood gas determinations, and chest x-ray.
• Cardiovascular: Status is acceptable at this time while on dopamine at 5 mcg/kg/min. Echocardiogram shows a patent ductus arteriosis. There also appears to be a slight abnormality to the pulmonary valve, which could be associated with his possible Noonan syndrome. He is going to receive indomethacin therapy.
• Gastrointestinal: Abdominal exam remains benign. He is NPO. He does have mild hyperbilirubinemia. Direct antibody test was negative. We will begin phototherapy at this time.
• Hematologic: Serial CBCs have been acceptable except for mild thrombocytopenia. We will continue to monitor, especially in light of the indomethacin therapy. He has not required any blood product transfusions since birth.
• Infectious Disease: Blood culture remains negative at this time. We have discontinued his gentamicin, and he is being placed on cefotaxime because of the indomethacin.
• Neurologic: Exam remains acceptable given his extreme prematurity. He will require screening intracranial ultrasound and long-term neurodevelopmental follow-up.
• Renal/Metabolic: Urine output remains adequate and renal function studies are acceptable. Previous metabolic parameters are acceptable. We will repeat in the morning.
• Fluids/Electrolytes/Nutrition: Weight loss is acceptable and electrolytes are in the more normal range today. We will adjust his TPN accordingly.
• Apnea/Bradycardia: None since birth.
• Health Care Maintenance: None yet.

SOCIAL HISTORY: Mom and dad are being kept up to date with regard to the patient’s condition. Their questions have been answered, and they are in agreement with the outlined management plan.

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