Progress Note, Ventilator Assist

Progress Note, Ventilator Assist

This is a subsequent hospital visit by Dr. Ortez for this patient.

LOCATION: Inpatient, Hospital

PATIENT: Manuel Sanchez

PHYSICIAN: Rolando Ortez, MD

SUBJECTIVE: This baby boy is slightly under 24 hours.

OBJECTIVE: Weight today is 1.851 kg (increased 43 grams over birth weight). OFC is 30.5 cm (unchanged). Intake and output from yesterday do appear adequate, although it was less than 24 hours. He has had no stool since birth. Vital signs reveal his temperature to be acceptable while being maintained on an open radiant warmer. Heart rate is generally in the 110s-140s. Respiratory rate is generally equal to the IMV (60). Mean blood pressures had decreased last night to the low 30s but are now in the low to mid 40s while on dopamine infusion.

PHYSICAL EXAMINATION: In general, he is pink concurrent with ventilator setting. He does appear slightly dysmorphic with eyes wide set and slightly down-slanting palpebral fissures. Ears appear low set and posteriorly rotated. Endotracheal tube is in place. Chest reveals symmetric expansion and the lungs are clear to auscultation on current ventilator settings. Cardiac exam reveals a regular rate without murmur or click. Peripheral pulses are 2+ and symmetric. Abdominal exam reveals an umbilical arterial catheter in place. Liver is palpable 1 cm below the right costal margin. No splenomegaly or masses were noted. Genital examination reveals normal male, testes are not palpable. Extremity examination reveals no fixed decreased range of motion, deformity, or joint abnormality. Neurologic exam reveals diffuse hypotonia. No focal deficits are appreciated.

CURRENT MEDICATIONS

• Ampicillin 90.4 mg IV q12h.
• Gentamicin 5.4 mg IV 1q18h.
• 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 settings of IMV 60, pressure 22/4, and Fio₂ 0.53 and revealed pH 7.3, Pco₂ 46.6, Po₂ 52.7, and bicarbonate 22.7. Chemistry panel this morning revealed sodium 123, potassium 5.7, chloride 93, glucose 66, BUN 12, creatinine 0.9, calcium 7.3, magnesium 5.4, phosphorus 6.8, bilirubin 4.4, alkaline phosphatase 200, ALT 14, AST 38, albumin 1.7, and total protein 3.6. Electrolytes were repeated and were unchanged. CBC with differential this morning revealed a white count of 8230 with 6 bands, 45 neutrophils, 31 lymphocytes, 7 monocytes, and 7 eosinophils. Platelet count was 98,000. Chest x-ray continues to show significant evidence of hyaline membrane disease.

IMPRESSIONS/RECOMMENDATIONS

• Less than 24-hour-old infant who was born at 30 weeks’ gestation. Based on clinical examination, he may have Noonan syndrome.
• Respiratory: He has evidence of hyaline membrane disease with respiratory failure. He had received two doses of surfactant and will receive a third dose soon. We will adjust his ventilator setting based on serial clinical examinations, pulse oximetry, arterial blood gas determinations, and chest x-rays. Will continue sedation and paralysis at this time. I would recommend a short course of steroids because of the intubation attempts when he is extubated.
• Cardiovascular: Cardiovascular status is acceptable at this time while on dopamine at 5 mcg/kg/min. Blood pressure has improved on inotropic support. I do not hear a murmur at this time. He may require echocardiography to evaluate for PDA depending on his clinical course.
• Gastrointestinal: Abdominal exam remains benign. He is NPO. He has mild hyperbilirubinemia, and mom is noted to have O positive blood and Rh. We are going to obtain a direct antibody test. Will follow with serial bilirubin determinations.
• Hematologic: He has developed a mild thrombocytopenia; will monitor.
• Infectious Disease: Blood culture remains negative; he is on ampicillin and gentamicin. We will check closely.
• Neurologic: Exam remains acceptable given his extreme prematurity. He will require screening intracranial ultrasounds and long-term neurodevelopmental follow-up.
• Renal/Metabolic: Urine output remains adequate at this time. Metabolic parameters were acceptable. Will monitor closely.
• Fluid/Electrolytes/Nutrition: He has gained some weight since birth. Multiple electrolyte dysfunctions are noted. This is partially due to dilution. We have restricted fluid somewhat and added various electrolytes/minerals to his TPN. We will monitor with serial chemistry panels.
• Apnea/Bradycardia: None since birth.
• Health Care Maintenance: None yet.

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

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