Wiliam Sepulvado



| |

|MEDICAL CHRONOLOGY - INSTRUCTIONS TO FOLLOW |

| |

|General Instructions: |

|Brief Summary/Flow of Events: |

|In the beginning of the chronology, a Brief Summary/Flow of Events outlining the significant medical events is provided which will give a general picture of the|

|focus points in the case |

| |

|Patient History: |

|Details related to the patient’s past history (medical, surgical, social and family history) present in the medical records |

| |

|Detailed Medical Chronology: |

|Information captured “as it is” in the medical records without alteration of the meaning. Type of information capture (all details/zoom-out model and relevant |

|details/zoom-in model) is as per the demands of the case which will be elaborated under the ‘Specific Instructions’ |

| |

|Reviewer’s Comments: |

|Comments on contradicting information and misinterpretations in the medical records, illegible handwritten notes, missing records, clarifications needed etc. |

|are given in italics and red font color and will appear as * Reviewer’s Comment |

| |

|Illegible Dates: Illegible and missing dates are presented as “00/00/0000”(mm/dd/yyyy format) |

| |

|Illegible Notes: Illegible handwritten notes are left as a blank space “_____” with a note as “Illegible Notes” in the heading of the particular |

|consultation/report. |

| |

|Specific Instructions: |

|The chronology focuses on the Labor and Delivery notes with subsequent complication of developmental delay as given below: |

|09/19/YYYY-04/23/YYYY: These records of the prenatal visits till the time of delivery has been summarized in detail including the lab reports and ultrasound |

|imaging to assess for any maternal complications |

|04/28/YYYY-05/02/YYYY: These records have been summarized in detail including the admission for active labor, all progress notes until delivery, labor and |

|delivery note, its associated complications and NICU notes |

|05/07/YYYY-10/31/YYYY: These records of the multiple pediatric visits of X year time have been reviewed and only those pertaining to developmental delay has |

|been summarized in brief to assess the infant’s status alone |

|The reference is given brown font when captured in the Occurrence column |

|The mother details are presented in blue font color for ease of reference |

| |

|Critical/Non-Critical Missing records: |

|What records/medical bills are needed |

|Hospital/ |

|Medical provider |

|Date/ Time period |

|Why we need the records/bills? |

|Is record missing confirmatory/ probable? |

| |

|All the Prenatal ultrasounds |

|Unknown |

|09/19/YYYY-04/28/YYYY |

|To assess if Cephalopelvic Disproportion (CPD) could have been assessed earlier |

|Confirmatory |

| |

|Labor and delivery sheet |

|XXXXX County Hospital |

|04/28/YYYY |

|To assess the complications of the infant during delivery including respiratory distress |

|Confirmatory |

| |

Brief Summary/Flow of Events

09/19/YYYY – 04/23/YYYY: Prenatal visits

09/19/YYYY-09/21/YYYY: Mother had multiple prenatal visits for ultrasound screening, vaginal bleeding and vaginal discharge (spotting) – Managed conservatively

04/04/YYYY - Ultrasound revealed cephalic presentation, with measurements of BPD 8.9, HC 31.8, AC 31.2, FL 7 3, EFW 2721, OFD 11.4, FHR 130 and AFI within normal limits

[pic]

04/28/YYYY – 05/02/YYYY: Admitted for term pregnancy – Attempted vacuum extraction - Delivered by cesarean section – Discharged home

04/28/YYYY:

@ 1935 hrs: Presented for irregular contractions – Vaginal exam revealed Dilation 3, effacement 70, Station -1, Presenting part: vertex

@ 2317 hrs and 2326 hrs: Vacuum applied multiple times per Dr. XXXXX

Assessed with Cephalopelvic Disproportion (CPD) and failure to descend – Taken for c-section

* Reviewer’s Comment: The patient went for C section owing to cephalopelvic disproportion. The Labor and Delivery note/ Procedure report including the vacuum extraction details are not available for review.

04/29/YYYY: @ 0024 hrs Male infant delivered by primary cesarean section secondary to failure to progress, cephalopelvic disproportion with meconium stained fluid – Assessed with decreased Apgars of 4, 6 and 9; questionable pneumothorax on the left - Infant admitted in NICU for respiratory distress

05/01/YYYY-05/03/YYYY: Infant managed in NICU – Discharged home

[pic]

05/03/YYYY-10/09/YYYY: Multiple Pediatric visits for developmental delay and multiple other conditions

09/01/YYYY: Assessed with speech fluency stuttering, delayed developmental milestones speech – Recommended speech therapy

09/30/YYYY-04/30/YYYY: Assessed with mild to moderate receptive language delay, mild expressive language delay; articulation, language and fluency disorders, mild to moderate sensorineural hearing loss – Managed with speech therapy and hearing aids

06/11/YYYY: Psychological Evaluation revealed Below Average Intelligence, Below Average Academic Achievement, Rule out Intellectual Disability, Phonological Disorder, Bilateral Hearing Aids, Symptoms of inattention are most likely secondary to significant learning problems

Patient History

Past Medical History: No relevant history

Surgical History: No relevant history

Family History: Significant for hearing loss, hypertension, and headache

Social History: No relevant history

Allergy: No known drug allergies

Detailed Chronology

|DATE |PROVIDER |OCCURRENCE/TREATMENT |PDF REF |

|09/19/YYYY |Hospital/ Provider |Emergency Room (ER) visit for Threatened Abortion (AB): |82, 133 |

| |Name | | |

| | |Her Last Menstrual Period (LMP) was 07/28/YYYY roughly, Estimated Date of Confinement (EDC) | |

| | |05/04/YYYY. This puts her about 7 weeks. She had a positive pregnancy test last week. No | |

| | |further spotting. She is not bleeding. Her cervix is closed. Weight 156. I have scheduled her | |

| | |for an ultrasound Friday for threatened AB. | |

|09/21/YYYY |Hospital/ Provider |Pre- Natal Flow record: Illegible notes |85, 83- 84 |

| |Name |Patient’s Blood type and Rh: O positive, Antibody negative, serology not recorded, rubella | |

| | |titer 60, pap test Within Normal Limits (WNL), blood sugar 89, negative for cervical culture, | |

| | |sickle cell test, Human Immuno Deficiency Virus (HIV), Hepatitis B and Chlamydia. No prior | |

| | |contraception. Vaginal discharge and bleeding (spotting) present since LMP. | |

| | |EDC: 04/30/YYYY, weight 154, Blood Pressure (BP) 121/79, pulse 89 | |

| | | | |

| | |Pregnant History: | |

| | |Gravida 2, Term 1, Preterm 0, Abort 0, Live 1. | |

| | |In 2006, a male child weighing 5#7 was delivered via vaginal delivery at 39th gestational week | |

| | |at XXXXX County Hospital- Emergency Department (ED). | |

|09/21/YYYY |Hospital/ Provider |Obstetrical (OB) Ultrasound: |122 |

| |Name |Fetal number- Single, Fetal cardiac activity and movement- Normal. | |

| | |Placenta location: Anterior, yolk sac 7 cm | |

| | |Expected Date of Delivery (EDD): 04/30/YYYY, Mental age (MA): 8w 2d | |

| | |Crown Rump Length (CRL) 1.7cm, Fetal Heart Rate (FHR) 155, Amniotic Fluid Index (AFI) within | |

| | |normal limits | |

|09/22/YYYY |Hospital/ Provider |Labs: |113-114 |

| |Name |Screening test negative for HBsAg, Rubella antibodies, IgG, Antibody screen, RPR and HIV. | |

| | |CBC, Platelet count and Differential count: No abnormalities detected. | |

|09/27/YYYY |Hospital/ Provider |Labs: |118 |

| |Name |Tests ordered: Pap Ig, rfx HPV all pathology | |

| | | | |

| | |Diagnosis: Negative for intraepithelial lesion and malignancy | |

|10/19/YYYY |Hospital/ Provider |OB visit: Illegible notes |82 |

| |Name |Weight 156, BP 122/74, Gestational Age (GA) 11 weeks 3 days. Positive fetal heart rate. No | |

| | |edema. _______ cramping. Decreased appetite. Prenatal vitamins changed per patient request. 4 | |

| | |weeks | |

|11/16/YYYY |Hospital/ Provider |OB visit: Illegible notes |82 |

| |Name |Weight 163, BP 120/62, GA 16 weeks. Positive fetal heart rate. No edema._______ | |

|11/20/YYYY |Hospital/ Provider |Labs: |111-112 |

| |Name |GA 16 weeks, maternal age at EDD 19.3, weight 163. | |

| | | | |

| | |Screening test negative for fetal Open Spina Bifida (OSB), Down syndrome and Trisomy 18. | |

|12/07/YYYY |Hospital/ Provider |OB visit: Illegible notes |82 |

| |Name |Weight 166, BP 121/76, GA 19 weeks, Fundal height 19, and no edema. | |

|12/07/YYYY |Hospital/ Provider |OB Ultrasound: |121 |

| |Name |MA 18 weeks 6 days, EDD 5/3/YYYY | |

| | |Presentation: Transverse head to maternal left, Placenta location: Anterior, Bi Parietal | |

| | |Diameter (BPD) 4.5, Head circumference (HC) 15.9, Abdominal circumference (AC) 13.7, Femur | |

| | |length (FL) 3.2, Estimated Fetal Weight (EFW) 296, Occipital Frontal Diameter (OFD) 5.4, FHR | |

| | |148, AFI within normal limits. | |

|01/09/YYYY – |Hospital/ Provider |Prenatal Flow Record: |80 |

|03/21/YYYY |Name |*Reviewer’s comment: The only available prenatal details from flow sheets are summarized below | |

| | |in a tabulation format for ease of review | |

| | | | |

| | | | |

| | |Weight | |

| | |BP | |

| | |GA | |

| | |Fundal height | |

| | |Fetal heart rate | |

| | | | |

| | |01/09/YYYY | |

| | |170 | |

| | |126/71 | |

| | |23 weeks 5 days | |

| | |25 | |

| | | | |

| | | | |

| | |02/01/YYYY | |

| | |172 | |

| | |140/78 | |

| | |26 weeks 5 days | |

| | |25 | |

| | | | |

| | | | |

| | |03/07/YYYY | |

| | |173 | |

| | |124/56 | |

| | |31 weeks 6 days | |

| | |30 | |

| | |160 | |

| | | | |

| | |03/21/YYYY | |

| | |175 | |

| | |138/78 | |

| | |33 weeks 6 days | |

| | |35 | |

| | | | |

| | | | |

|03/24/YYYY |Hospital/ Provider |Labs: |81 |

| |Name |Negative for Streptococci Group B culture | |

|04/04/YYYY |Hospital/ Provider |OB Ultrasound: |120 |

| |Name |MA 35w 5d, EDD 5/4/YYYY, Presentation: Cephalic, Placenta location: Anterior fundal | |

| | |BPD 8.9, HC 31.8, AC 31.2, FL 7, EFW 2721, OFD 11.4, FHR 130, AFI within normal limits. | |

| | |Positive for fetal cardiac activity, fetal movement, three vessel cord, 4 chamber heart, fetal | |

| | |stomach, bladder, kidneys, spine and cord insert. | |

|04/28/YYYY |Hospital/ Provider |OB visit for irregular contractions: |598-599, 605, 725,|

| |Name |Contractions are irregular and started at 0800 hrs. |727 |

| | |Last solids and drank liquids @ 1500 hrs. | |

| | | | |

| | |Arrival @ 1935 hrs: (XXXXX, RN) | |

| | |Vitals: BP 104/64, temperature 98.8, pulse 72, respiration 18 | |

| | |Dilation 3, effacement 70, Station -1, presenting part: vertex | |

| | |FHT 140, reactive variability and negative Group B streptococcus. | |

| | |Previous OB complications: Hyper emesis | |

| | |Repair sutures and medications: 2.0 Vicryl | |

| | | | |

| | |@ 2126 hrs: (XXXXX, RN) | |

| | |Pain 10/10, Dilation 5-6, Effacement 90%, Station +1, FHT 150, FHM external, Variability: | |

| | |Reactive. | |

| | |Negative deceleration. Intra Venous (IV) fluid Lactated Ringers (LR) | |

| | |Contraction: Moderate strength, 1-2 min frequency | |

| | |Vertex position | |

| | | | |

| | |@ 2146 hrs: (XXXXX, RN) | |

| | |1 mg Stadol, Intra Venous Push (IVP), LR right hand 125 mg Intra Venous Fluid (IVF), 18 g | |

| | |Cathlon to right hand X 2 attempts blood specimen collected and sent to lab. | |

| | | | |

| | |@ 2248 hrs: (XXXXX, RN) | |

| | |Strength: Strong, every 1 min, duration 1 min, FHT 120, FHM external. Vertex position. | |

| | | | |

| | |@ 2250 hrs: (XXXXX, RN) | |

| | |Patient off monitor. Transferred to delivery room via cart in stable condition. | |

| | | | |

| | |Artificial Rupture Of Membrane (AROM) at 1 hour 10 min before delivery | |

| | | | |

| | |@ 2256-2300 hours Fetal monitoring strip: (Ref: 725) | |

| | |[pic] | |

| | |MD comments: Fetal strip showing minimal beat to beat variability and absence of accelerations.| |

| | | | |

| | |@ 2317 hrs: Vacuum applied x 4 per Dr. XXXXX | |

| | | | |

| | |@ 2320 hours Fetal monitoring strip: (Ref: 727) | |

| | |[pic] | |

| | |MD comments: Fetal strip showing persistent prolonged decelerations. | |

| | | | |

| | |@ 2326 hrs: Vacuum applied x 4 per Dr. XXXXX | |

| | | | |

| | |* Reviewer’s Comment: The patient went for c-section owing to cephalopelvic disproportion. The | |

| | |Labor and Delivery note/ Procedure report including the vacuum extraction details are not | |

| | |available for review. | |

|04/29/YYYY |Hospital/ Provider |History and Physical: |126-127 |

| |Name |Chief Complaint: Onset of labor, failure to descend and cephalopelvic disproportion. | |

| | | | |

| | |History of Present Illness: The patient was taken to the delivery room at 10 cm dilatations and| |

| | |100 effacement. She failed to descend beyond a plus one station on numerous attempts position | |

| | |wise, including flexing the hips. She was even placed in the hands and knees position and in | |

| | |the kneeling position with failed vacuum extraction with episiotomy. She is now going to have | |

| | |cesarean section. | |

| | | | |

| | |Review Of System: Unremarkable, except for history of present illness. | |

| | | | |

| | |Examination: | |

| | |Vitals: BP 115/72, respiration 20, temperature 98.6, pulse 90. | |

| | |She is a well-developed gravida Afro-American female in mild distress. | |

| | |Head: Atraumatic and normocephalic. Pupils are equally round and reactive to light | |

| | |accommodation. Extraocular movements are intact. Cranial nerves 2 through 12 are grossly | |

| | |intact. Tympanic membranes (TM) clear. Nose is clear. Oropharynx is clear. | |

| | |Neck: Supple | |

| | |Lungs: Clear to auscultation bilaterally | |

| | |Heart: Regular rate and rhythm without gallops, rubs or murmur | |

| | |Abdomen: Soft and non-tender. Fundal height is 39 cm and fetal heart tones are in the 130s. | |

| | |Genitourinary (GU), Rectal, Skin: Normal | |

| | |Genitalia: Episiotomy repair and midline in place. Cervix is 10 cm. 100% effaced plus one | |

| | |station | |

| | |Extremities: No cyanosis or edema | |

| | |Neuro: Intact | |

| | | | |

| | |Impression: Cephalopelvic disproportion (CPD) and failure to descend. | |

| | | | |

| | |Plan: Admit and perform cesarean section | |

|04/29/YYYY |Hospital/ Provider |@ 0000 hours Fetal monitoring strip: |732 |

| |Name | | |

| | | | |

| | |MD comments: Fetal strip showing absence of beat to beat variability and absence of | |

| | |accelerations. | |

|04/29/YYYY |Hospital/ Provider |Operative Report for primary cesarean section: |132 |

| |Name |Pre-operative diagnosis: CPD, failure to progress | |

| | |Post-operative diagnosis: Same, meconium stained fluid | |

| | |Anesthesia: General | |

| | | | |

| | |Procedure: After the patient had an unsuccessful vaginal delivery with vacuum assistance it was| |

| | |obvious there was CPD and she was brought to the OR where general anesthesia was obtained. A | |

| | |Pfannenstiel incision was made and carried sharply through the fascia. The fascia was opened | |

| | |sharply. The rectus reflected off the rectus muscle and the rectus divided along the midline. | |

| | | | |

| | |The peritoneum was sharply entered. Bladder flap was constructed and a low transverse incision | |

| | |was made. Meconium stained fluid was observed. The infant was male in the occiput posterior | |

| | |position with the head molded into the pelvis. The infant was delivered and tended by myself | |

| | |while Dr. XXXXX closed. | |

| | | | |

| | |The placenta was manually extracted and the uterus exteriorized, curetted with a towel and | |

| | |irrigation with antibiotic solution was performed. The lower transverse segment was closed with| |

| | |running locking #1 Vicryl. The anterior and posterior gutters were irrigated free of clots. | |

| | |Good hemostasis was noted. Tubes and ovaries were normal. The uterus was returned to the | |

| | |abdominal cavity by Dr. XXXXX. | |

| | | | |

| | |The rectus was approximated and the fascia was closed with running #I Vicryl, subcutaneous 2-0 | |

| | |Vicryl, skin with auto suture. The patient was stable and to the Recovery Room (RR). | |

|04/29/YYYY |Hospital/ Provider |Nurse Notes: |599 |

| |Name |At 0024hrs a male infant was delivered. | |

| | | | |

| | |APGAR score: | |

| | |1 min: 4, 5 min: 6, 10 min: 9 | |

| | | | |

| | |Weight 7 lbs. 8 oz. | |

| | | | |

| | |No physical abnormalities noted. No intake taken. | |

| | | | |

| | |Output: Urine, meconium | |

|04/29/YYYY |Hospital/ Provider |Newborn Transitional Record: Illegible notes |546, 561 |

| |Name |@ 0040 hrs: (Ref 546) | |

| | |Vitals: Respiration 98, temperature 95.4, pulse 156, oxygen saturation 93% | |

| | | | |

| | |@ 0045 hrs: (Ref 546, 561) | |

| | |Received to nursery from OR. Weighed and placed on radiant warmer with warm, humidified O2 at | |

| | |100% per Oxyhood. Dr. XXXXX arrives. Chest X- ray ordered. Infant grunting loudly. No nasal | |

| | |flaring. No retractions. | |

| | |Tone: floppy, skin color blue, head: large caput, lungs wet sound, good breath sounds and harsh| |

| | |sounding cry. | |

| | | | |

| | |@ 0055 hrs: (Ref 546) | |

| | |Chest X- ray done. Infant active and crying. IV established. Blood culture drawn. IV dislodged | |

| | |with active infant’s ______. 24 gauge Cathlon inserted in right forearm and taped securely. | |

| | |Dextrose 5 ½ Saline started at 10cc/hr ________ | |

| | | | |

| | |@ 0100: Current Medications: Erythromycin eye ointment both eyes, Vitamin K Intra Muscular (IM)| |

| | |right thigh, Hepatitis B vaccine IM left thigh, HBIG vaccine IM and triple dye applied via | |

| | |cord. | |

| | | | |

| | |@ 0115 hrs: Ampicillin, then Claforan doses given IVP slowly. Tolerated well. | |

| | | | |

| | |@ 0140 hrs: Vitals Respiration 80, temperature 98.5, pulse 141, oxygen saturation 98% | |

| | | | |

| | |@ 0200 hrs: Active and crying. Irritable. Cries and kicks without any stimulus | |

| | | | |

| | |@ 0215 hrs: Asleep and quiet for first time since admission. Tachypnea with respiration 90. Now| |

| | |resting on abdomen under radiant warmer and 100% oxygen. | |

| | | | |

| | |@ 0245 hrs: Quiet only a few minutes. Then crying again. Vital signs stable. | |

| | | | |

| | |@ 0240 hrs: Vitals Respiration 90, temperature 98.9, pulse 155, oxygen saturation 100% | |

| | | | |

| | |@ 0340 hrs: Vitals: Respiration 172, temperature 98.6, pulse 172, oxygen saturation 100% | |

| | | | |

| | |@ 0440 hrs: Vitals Respiration 82, temperature 98.4, pulse 117, oxygen saturation 100% | |

| | | | |

| | |@ 0500 hrs: Vital signs stable. Excessive crying. Remains on radiant warmer. Tachypnea. Under | |

| | |100% O2 per Oxyhood | |

| | | | |

| | |@ 0510 hrs: 2 hour glucose: 54 | |

|04/29/YYYY |Hospital/ Provider |New born Assessment on discharge: Illegible notes |543-544 |

| |Name | | |

| | |Complications of Antepartum and delivery: Primary C-section, CPD/FTP. Vacuum and ____ x 4 per | |

| | |Dr. XXXXX. Probable meconium aspiration. | |

| | | | |

| | |On Admission @ 0100 hrs: | |

| | |Weight 7 lbs. 8 oz; 3406 grams, Head circumference: 14, Length 20. | |

| | | | |

| | |On Discharge @ 0800 hrs: | |

| | |Blood type: B positive, blood sugar 54, hematocrit 37.3, hemoglobin electrophoresis 12.1 and | |

| | |negative for Coombs and Hepatitis B. | |

| | | | |

| | |Complications in Nursery: Low oxygen when out of Oxyhood. Meconium aspiration. | |

| | | | |

| | |Feeding: Nil per oral | |

| | | | |

| | |Discharge Diagnosis: _______, Meconium aspiration | |

| | | | |

| | |Newborn Discharge Assessment: | |

| | |ID bands verified between mother and baby. Foot prints complete and mother offered a copy. | |

| | |Newborn transferred to MCU at UMC | |

| | |Newborn will not reside with the mother. | |

| | | | |

| | |Skin condition and ability to void/ stool: Good | |

| | | | |

| | |Medications on discharge: Dextrose ¼ NS at 10 ml/ hour, Ampicillin 200 mg IV, Claforan 200 mg. | |

| | | | |

| | |Unresolved issues: Transfer to MCU at UMC | |

| | |Assessment of newborn: Oxygen saturation 100% Oxyhood. Report to MCU. IV site right arm with | |

| | |24g intact. IV fluid, infusing well. Active muscle tone, color pink. Respiratory tachypnea. | |

| | |Cord clamp intact. ______ | |

| | | | |

| | |Discharged to UMC | |

|04/29/YYYY |Hospital/ Provider |Discharge Summary: |138, 599, 624, 558|

| |Name |Diagnosis: Probable meconium aspiration syndrome | |

| | | | |

| | |History: The patient had an uncomplicated pregnancy. Attempts have been made by Dr. XXXXX at | |

| | |vaginal delivery when she became complete. Vacuum extractor had been placed several times | |

| | |without success and the decision was made to go to cesarean. At the cesarean delivery there was| |

| | |fairly moderate to thick meconium stained fluid noted. The infant initially had been suctioned | |

| | |aggressively on the operating field but had decreased Apgars of 4, 6 and 9. | |

| | | | |

| | |Bag valve mask resuscitation had to be performed. I did visualize the cords but not after the | |

| | |baby had taken the first breath. The initial X-rays showed some bilateral perihilar infiltrates| |

| | |consistent with probably aspiration. The child has been under the Oxy-Hood all night and has | |

| | |been crying incessantly. | |

| | | | |

| | |This morning the child is alert and active. Oxygen saturations are nearly 100% under the | |

| | |Oxy-Hood but when taken out from the Oxy-Hood they drop fairly quickly but he has been able to | |

| | |maintain oxygen saturations for a while in the 90 percentile but when he starts crying he does | |

| | |become cyanotic and his oxygen saturation drop. | |

| | | | |

| | |Chest X-ray shows improvement of the infiltrates. There is a questionable pneumothorax on the | |

| | |left and we are waiting the radiologist’s interpretation. My impression, however, is that the | |

| | |child has meconium aspiration syndrome. My other concern is the possibility of a subdural or | |

| | |epidural hematoma. | |

| | | | |

| | |The caput that was present at birth has pretty much resolved; however, due to the infant’s | |

| | |incessant crying I am concerned about the possibility of a subdural. Ampicillin and Claforan | |

| | |were given after appropriate cultures. The mother did receive Ampicillin in labor. I have | |

| | |contacted Dr. XXXXX at UMC, Neonatal ICU, and they will arrive as soon as possible to transport| |

| | |the baby to UMC. | |

| | | | |

| | |Transfer record: (Ref 558) | |

| | |The patient is transferred in an unstable condition to the NICU via ambulance with the | |

| | |diagnosis of meconium aspiration for special care. | |

|04/29/YYYY |Hospital/ Provider |NICU Report: Illegible notes |624-627, 628, 550,|

| |Name |Birth:(Ref 624) |609 |

| | |Time 0024 hrs, Weight 3.406, Length 50.5 cm, HC 35.5 cm, GA 39 weeks 6 days, Growth: adequate | |

| | |for gestational age. Amniotic fluid: Meconium stained. | |

| | | | |

| | |Admission Laboratory studies: (Ref 625) | |

| | |WBC 19.3, Hemoglobin 12.1, hematocrit 37.3, platelets 403. Blood culture pending | |

| | | | |

| | |Physical Examination: | |

| | |Vitals: BP 66/39, respiration 36, temperature 97.7, pulse 144 | |

| | |Bed: Radiant warmer | |

| | |Head, Eyes, Ears, Nose, Throat (HEENT): Normocephalic, moderate molding with caput succedaneum,| |

| | |anterior fontanelle soft and open, eyes clear, no discharge, ears normoset, no tags, no pits | |

| | |and palate intact, gums pink, no teeth | |

| | |Respiratory: Bilateral breath sounds equal and clear and easy work of breathing, occasional | |

| | |tachypnea | |

| | |Cardiac: Regular Rate and Rhythm (RRR), no obvious murmur, femoral and brachial pulses 2+ and | |

| | |equal and cap refill ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download