Wiliam Sepulvado
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|MEDICAL CHRONOLOGY - INSTRUCTIONS TO FOLLOW |
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|General Instructions: |
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|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 |
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|Patient History: |
|Details related to the patient’s past history (medical, surgical, social and family history) present in the medical records |
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|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’ |
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|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 |
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|Illegible Dates: Illegible and missing dates are presented as “00/00/0000”(mm/dd/yyyy format) |
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|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. |
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|Specific Instructions: |
|The chronology focuses on the clinical presentation of uterine contractions, monitoring in Labor and Delivery and cesarean section surgery |
|until birth on 12/30/YYYY, in timeline manner. |
|We have followed 24-hour format. |
|Baby records from 12/30/YYYY-01/06/YYYY are given in brief to show know the neurological and respiratory condition. |
|The mother records are given in blue color. |
|The prenatal and fetal monitoring snapshots are provided. |
|The PDF reference is given brown color in the Occurrence column. |
Brief Summary/Flow of Events
04/20/YYYY-12/21/YYYY: Multiple pre-natal visits - Assessed fetus with normal heart motion, kidney, bladder
[pic]
12/30/YYYY: ABC Hospital
@1258 hrs: ER visit for uterine contractions
@1334 hrs: With spontaneous rupture of membrane and thick meconium
@1345 hrs: Cardio tocometer on – Maternal oxygen saturation (97%) and heart rate (102)
@1346-1350 hrs: Signal loss in tocometer – Maternal oxygen saturation (86%)
@1355 hrs: Maternal oxygen saturation (79%)
@1402-1500 hrs: Admit to Labor and Delivery for premature rupture of membranes - With minimal variability, no acceleration and deceleration, irregular contraction frequency – Continuous signal loss in monitor
@1507 hrs: Planned for primary cesarean section
@1529 hrs: Underwent cesarean section for un-reassuring fetal heart rate tracing and thick meconium at 36 weeks gestation
@1531 hrs: Delivered baby boy – APGAR score: 3/5/5 - – Intubated for respiratory distress
@1555 hrs: Baby floppy, no active movements – Recommended admission to Neonatal Intensive Care Unit (NICU) for respiratory distress
[pic]
12/31/YYYY: With hypotonia of neck and trunk – Recommended Neurology consult and head ultrasound
01/01/YYYY: Neurology consultation: Baby with no cry and movements, poor arm flexion and severe head lag traction - Diagnosed with hypotonia, diminished strength – Recommended MRI brain
01/02/YYYY: Underwent lumbar puncture – Samples of cerebro spinal fluid collected
[pic]
01/03/YYYY-01/06/YYYY:
01/03/YYYY: Echocardiogram showed mild right ventricular hypertrophy – Head ultrasound showed intraventricular hemorrhage of both lateral ventricles and distended third and lateral ventricles – MRI brain showed mild enlargement of lateral and third ventricles
01/04/YYYY: Baby is not alert, eyes closed – Recommended Video Electro Encephalogram (EEG)
[pic]
01/05/YYYY: Video EEG showed clonus and myoclonic jerks of the extremities and no seizure or epileptic changes – Recommended Neurology consult and genetic consult
01/06/YYYY: Neurology consultation: Diagnosed with neonatal encephalopathy – Recommended MRI, lumbar puncture, chromosomal microarray – Transferred to XYZ for metabolic work-up and management
*Reviewer’s comment: No further records are available
Maternal History
Past Medical History: No significant history.
Pregnancy history: No significant history.
Surgical History: Breast augmentation, sinus surgery.
Family History: History not taken.
Social History: Negative.
Allergy: No known allergy.
Detailed Chronology
|DATE |PROVIDER |OCCURRENCE/TREATMENT |PDF |
| | | |REF |
|10/15/YYYY-01/25/Y|Multiple providers |Multiple diagnostic reports for trauma and pap test: |561-568 |
|YYY | |CT lumbosacral spine (Ref. 566-567), CT-abdomen and pelvis (Ref. 568), Correspondence to Dr. Xxxxx regarding MRI of | |
| | |lumbosacral spine (Ref. 565), Pathology Report (Ref. 561-562) | |
| | | | |
| | |*Reviewer’s comment: There are no significant details, hence not captured. | |
|07/08/YYYY |BioReference |Labs: |563-564 |
| |Laboratories |Complete Blood Count (CBC): Normal | |
| | |Blood group: B positive | |
| | |Ab. screening, HBsAg, HIV and cystic fibrosis mutation: Negative | |
|07/10/YYYY |Genzyme |Analysis for spinal muscular hypertrophy: |585-586 |
| | |Clinical data: Carrier test. | |
| |Xxx, Ph. D, FACMG |Date of collection: 07/06/YYYY | |
| | |Specimen: Peripheral blood | |
| | | | |
| | |Results: SMN1 copy number: 2 (Reduced carrier risk) | |
|07/18/YYYY |ABC Perinatal Center |Correspondence to Dr. Xxxxx regarding visit for cramping: |587-588, |
| | |Indication: 1st trimester screen. Cramping. |582 |
| |Xxxx, M.D., F.A.C.O.G.| | |
| | |LMP: 04/20/YYYY | |
| | |EDC: 01/25/YYYY | |
| | | | |
| | |First trimester scan: | |
| | | | |
| | |Impression: Normal intrauterine pregnancy. | |
| | | | |
| | |Follow-up: | |
| | |Planned in 5 weeks, date: 08/16/YYYY, time: 1730 hours Modified Sequential | |
| | |Planned in 8 weeks, date: 09/09/YYYY, time: 0900 hours for anatomy assessment. | |
|07/19/YYYY |Genzyme |Sequential screen (Down syndrome, Trisomy 18): |582 |
| | |Collected date: 07/18/YYYY | |
| |XXX , Ph.D. |Specimen type: Bloodspot | |
| | | | |
| | |Interpretation: Final result pending. | |
|08/17/YYYY |Genzyme |Sequential screen: |581 |
| | |Collected date: 08/16/YYYY | |
| |XXX , Ph.D. |Specimen: Serum | |
| | | | |
| | |Final result: Screen negative. | |
|09/09/YYYY |ABC Perinatal Center |Correspondence to Dr. Xxxxx regarding visit for suspected fetal abnormality: |578-580 |
| | |General evaluation: | |
| |Xxxx, M.D., F.A.C.O.G.|Fetal heart activity: Present. Fetal heart rate: 1457bpm. | |
| | |Presentation: Cephalic | |
| | |Fetal movement: Visible. | |
| | |Amniotic fluid: Normal. | |
| | |Cord: 3 vessels. | |
| | |Placenta: Posterior. Placenta grade: Grade 0. | |
| | | | |
| | |Report summary: | |
| | |Impression: Incomplete ultrasound due to fetal position. | |
| | | | |
| | |Recommendation: We recommend a further ultrasound scan in 30 weeks. | |
| | | | |
| | |Follow-up: Suggested in 3 weeks, date: 09/30/YYYY, time: 1800 hours for repeat evaluation. | |
|10/07/YYYY |ABC Perinatal Center |Correspondence to Dr. Xxxxx regarding visit for suspected fetal abnormality: |576-577 |
| | | | |
| |Xxxx, M.D., F.A.C.O.G.|Report summary: | |
| | |Impression: Fetus appears to be normal, no major malformation was identified. | |
|10/10/YYYY |Quest Diagnostics |Labs: |575 |
| | |Glucose: 126 | |
|11/07/YYYY |Obstetrics & |Obstetrics ultrasound for fetal growth: |571-574 |
| |Gynecology |2D measurements: | |
| | |BPD: 7.91cm | |
| | |HC: 27.10cm | |
| | |AC: 23.96cm | |
| | |FL: 5.42cm | |
| | |OFD: 9.25cm | |
| | |FL/BPD ratio: 68.43 | |
| | |FL/AC: 22.60 | |
| | |HC/AC ratio: 1.13 | |
| | |FL/HC ratio: 19.99 | |
| | | | |
| | |Amniotic Fluid Index (AFI): | |
| | |AF1: 2.26cm | |
| | |AF2: 3.35cm | |
| | |AF3: 2.92cm | |
| | |AF4: 5.94cm | |
| | |AFI: 14.47cm | |
| | | | |
| | |Estimated Fetal Weight (EFW): | |
| | |EFW1: 1277gm | |
| | |EFW1-Gestational Age (GA): 28weeks 6 days | |
| | |EFW1-Growth Percentile (GP): 16.4% | |
| | | | |
| | |Doppler measurements: FHR: 150 bpm | |
| | |HR: 224 bpm | |
| | | | |
| | |Fetal description: | |
| | |Fetal lie: Cephalic | |
| | |Face, left kidney, 3 vessel cord, stomach, bladder, cord insertion, right kidney, diaphragm: Seen | |
| | | | |
| | |Fetal extremities: | |
| | |Upper and lower extremities: Seen | |
| | | | |
| | |Fetal heart: Cardiac activity and 4C heart: Seen | |
| | | | |
| | |Fetal environment: | |
| | |Placental location: Posterior | |
| | |Amniotic fluid: Normal | |
| | |Placental grade: 1 | |
| | | | |
| | |Fetus score: | |
| | |FHR: 2 | |
| | |FM: 2 | |
|12/06/YYYY |Xxxx, M.D. |Ultrasound pelvis: |569-570 |
| | |Indication: Estimated Fetal Weight (EFW) | |
| | | | |
| | |Gestational Age (GA) by ultrasound: 32 4/7 weeks | |
| | | | |
| | |Biometry: | |
| | |BPD: 85mm | |
| | |Femur: 62mm | |
| | |HC: 307mm | |
| | |AC: 281mm | |
| | |HC/AC: 1.09 | |
| | |FL/AC: 0.22 | |
| | |EFW: 1992 gm | |
| | |FHR: 139 bpm | |
| | | | |
| | |Presentation/cord/placenta/fluid/cervix: | |
| | |Presentation: Cephalic | |
| | |Placenta: Anterior. There is no evidence of placenta previa. Grade 2 | |
| | |Amniotic fluid: Maximum vertical pocket: 58mm. Normal (AFI: 161 mm) | |
| | |Cervix: Suboptimal visualization | |
| | | | |
| | |Fetal anatomic survey: | |
| | |Normal: Fetal heart motion, stomach, left kidney, right kidney and bladder. | |
| | | | |
| | |Abnormal: None identified. | |
| | | | |
| | |Amniotic fluid volume: | |
| | |Normal: Total AFI: 161mm, normal. 56 percentile | |
| | | | |
| | |Biophysical profile: 8 out of 8 | |
| | | | |
| | |Correspondence to Dr. Xxxx regarding ultrasound evaluation for fetal growth: | |
| | |The patient reports no obstetrical complaints at this point. She reports having a normal fetal anatomy at an Outside| |
| | |Clinic. | |
| | | | |
| | |Ultrasound: Reviewed. | |
| | | | |
| | |Follow-up if clinically indicated. | |
|08/03/YYYY-12/21/Y|Not available |Pre natal record: Illegible notes |329 |
|YYY | |Reviewer’s comment: We are unable to decipher the notes as the quality of the record is very poor. Hence the | |
| | |snapshot of the prenatal visit details is captured. | |
| | | | |
| | |[pic] | |
|ABC Hospital |
|12/30/YYYY |ABC Hospital |ER visit for uterine contractions: |16-17, 376|
| | |@1258 hrs: (Xxx, R.N.) | |
| | |Patient admitted to ‘EROB3’ | |
| | | | |
| | |@1334 hrs: (Xxxxx, M.D.) | |
| | |Cervical dilation: 3, cervical effacement: 100. | |
| | |Membranes: Spontaneous Rupture Of Membrane (SROM). Fluid: Thick meconium. Fetal station: -2 | |
| | | | |
| | |@1345 hrs: Monitor status: On | |
| | |Recorder status: Off | |
| | |FHR1 measurement method: No transducer | |
| | |FHR2 measurement method: US | |
| | |Maternal Heart Rate (MHR) measurement method: No transducer | |
| | |Toco measurement method: External | |
| | |MHR measurement method: SpO2 | |
| | |Maternal SpO2: 97% | |
| | |MHR: 102 Beats Per Minute (bpm) | |
| | | | |
| | |Alert settings: | |
| | |Basic alerting | |
| | |Severe tachycardia 180bpm for 300 seconds | |
| | |Tachycardia 160 bpm for 300 seconds | |
| | |Bradycardia 110 bpm for 240 seconds | |
| | |Severe bradycardia 100 bpm for 120 seconds | |
| | |Signal loss 25% within 5 minutes | |
| | |Non Stress Test (NST) off | |
| | | | |
| | |@1346 hrs: FHR2: Signal loss. Bad FHR signal. Please adjust FHR sensor. | |
| | | | |
| | |@1350 hrs: | |
| | |FHR2: Signal loss | |
| | |Critical FHR. Please check patient and FHR sensor | |
| | |Maternal SpO2: 86 | |
| | | | |
| | |@1355 hrs: Maternal SpO2: 79 | |
| | | | |
| | |@1346-1356 hrs: Fetal monitoring strips: | |
| | |*Reviewer’s comment: We note that there is persistent bradycardia. | |
| | | | |
| | |[pic] | |
| | | | |
| | |[pic] | |
| | | | |
| | |@1356 hrs: Recorder status: On | |
| | |@1357 hrs: Maternal blood pressure: 152/115, mean value: 130 mmHg | |
| | | | |
| | |@1358 hrs: | |
| | |Maternal blood pressure: 123/81, mean value: 94 mmHg | |
| | |Maternal heart rate (NIBP): 84 | |
| | |MHR measurement method: No transducer | |
| | |Recorder status: Off | |
| | |Monitor status: Off | |
|12/30/YYYY |Xxxxx, M.D. |@1402 hrs: L&D - History and Physical: |436-438, |
| | |Temperature: 99.8, pulse: 87, RR: 18, SpO2: 98%, BP: 123/81 |372-374, |
| | |Height: 61 inch, weight: 136 lb |546 |
| | | | |
| | |General: Within normal limits, alert, oriented x3. Calm, appropriate and cooperative. No acute distress. Skin color | |
| | |normal for ethnicity. Skin dry and warm. Tolerates activity without distress. | |
| | | | |
| | |Neurological exam: Not performed. | |
| | |Cardiovascular: Within normal limits (heart rate regular, nail beds pink, no edema. Dorsalis pedis and radial pulses| |
| | |normal bilaterally). | |
| | |Abdominal exam: Abdomen soft, gravid uterus noted. | |
| | |Estimated fetal weight: 3,200gm. | |
| | | | |
| | |Testing: | |
| | |Type of sonogram: Abdominal | |
| | |Presentation: Cephalic | |
| | | | |
| | |Pelvic exam: | |
| | |FHR: 150 bpm. | |
| | |Presentation: Cephalic. | |
| | |Membrane status: Spontaneous rupture (meconium). | |
| | |Dilation: 3. | |
| | |Effacement: 100. | |
| | |Station: -2. | |
| | |Speculum: Grossly ruptured. | |
| | | | |
| | |Assessment: (Ref. 546) | |
| | |Previous pregnancy complications: None | |
| | |Diabetes: Not identified. | |
| | | | |
| | |Attending diagnosis: Premature Rupture Of Membrane (PROM). | |
| | |Plan of care: Admit. EFM/Toco, IVH/Nil Per Oral (NPO), admission labs, Penicillin for Group B Streptococci (GBS) | |
| | |prophylaxis, discuss with Dr. Xxxx | |
| | | | |
| | |Condition on discharge: Stable. | |
| | |Attending discharge disposition: Admit to Labor and Delivery. | |
|12/30/YYYY |ABC Hospital |@1410 hrs: Consent for anesthesia, obstetrical care, vaginal delivery and possible cesarean section |347-348 |
|12/30/YYYY | |Cardio tocometer monitoring: |14-15 |
| | |@1419 hrs: Monitor status: On | |
| | | | |
| | |FHR1 measurement method: No transducer | |
| | |FHR2 measurement method: US | |
| | |MHR measurement method: No transducer | |
| | |Toco measurement method: External | |
| | | | |
| | |@1420 hrs: Recorder status: On | |
| | |MHR measurement method: SpO2 | |
| | |MHR measurement method: No transducer | |
|12/30/YYYY |Xxxxx, M.D. |@1421 hrs: MD pelvic exam: |437 |
| | |Non-Stress test (NST)/Contraction Stress Test (CST): | |
| | |FHR: 150 bpm. | |
| | |Frequency: Irregular. | |
| | |Variability: Minimal (3-5). | |
| | |Accelerations: No. | |
| | |Decelerations: None. | |
| | |NST: Non-reactive. | |
|12/30/YYYY |ABC Hospital |@1423 hrs: L&D notes: (Ref. 15) |15, 376 |
| | |Maternal blood pressure: 137/93, mean value: 110 | |
| | |Maternal heart rate (NIBP): 85 | |
| | | | |
| | |@1445 hrs: Obstetrics and Gynecology notes – Addendum: (Xxxxx, M.D.) (Ref. 376) | |
| | | | |
| | |Cervical status: | |
| | |Dilation: 4-5 | |
| | |Effacement: 100 | |
| | |Station: -2 | |
| | |Membrane: SROM, meconium | |
| | | | |
| | |Electronic Fetal Monitoring (EFM): | |
| | |Baseline: 150, variability: Minimal, acceleration: No, deceleration: No, category: 2, contraction frequency: Every 3| |
| | |minutes. | |
|12/30/YYYY |ABC Hospital |Labor and delivery notes: |17, 375 |
| | |@1448 hrs: FHR2: Signal loss | |
| | |Bad FHR signal. Please adjust FHR sensor. | |
| | | | |
| | |FHR2: Signal loss | |
| | |Critical FHR. Please adjust FHR sensor. | |
| | | | |
| | |@1449 hrs: (Xxxxx, M.D.) | |
| | |Cervical dilation: 4-5 | |
| | | | |
| | |@1452 hrs: FHR2: Signal loss. Critical FHR. Please check patient and FHR sensor. | |
| | | | |
| | |@1456 hrs: | |
| | |FHR1 measurement method: DECG | |
| | |FHR2 measurement method: No transducer | |
|12/30/YYYY | Xxxx, M.D. |@1500 hrs: L&D notes: |543 |
| | |FHR: 155 | |
| | |Variability: Absent (0-2) | |
| | |Accelerations: No | |
| | |Decelerations: None | |
| | | | |
| | |Oxygen via face mask: 8 Liter Per Minute (LPM) | |
| | | | |
| | |Contraction frequency: 3-5. | |
| | |Contraction duration: 70-80. | |
| | |Contraction intensity: Moderate. | |
| | |Uterine resting tone: Soft. | |
|12/30/YYYY |Xxxxx, M.D. |@1507 hrs: Obstetrics and Gynecology consultation for thick meconium and abnormal FHR: |375-376 |
| | |Went to place Fetal Scalp Electrode (FSE) on the patient. Exam is unchanged. Fore bag ruptured. Thick meconium | |
| | |noted. Due to patients early gestational age, category 2 FHT and thick meconium, we have decided to proceed to | |
| | |cesarean delivery. A discussion with the patient and her family at the bedside went over risk, benefit and | |
| | |alternatives. She expressed understanding of the situation. | |
| | | | |
| | |Problem list: SROM with meconium, preterm, 36+weeks. | |
| | | | |
| | |Subjective: Patient complains of contractions, does not desire analgesia at this time. | |
| | | | |
| | |Assessment: G1P0 at 36 2/7 weeks with SROM, in labor, Category 2 tracing. | |
| | | | |
| | |Plan of care: | |
| | |Patient given oxygen, placed in LLP. | |
| | |Counseled patient on possibility of cesarean section given category 2 tracing, meconium, and patient understands and| |
| | |agrees if necessary. | |
| | |EFM/toco. | |
| | |Discussed with Dr. Xxxx. | |
| | | | |
| | |Pitocin given: No. | |
|12/30/YYYY |ABC Hospital |@1513 hrs: L&D notes: |17 |
| | |FHR1: Signal loss | |
| | |Bad FHR signal. Please adjust FHR sensor. | |
| | | | |
| | |@1514 hrs: Monitor status: Off. | |
|12/30/YYYY | |Anesthesia record: Illegible notes |349-351, |
| | |@1516 hrs: Anesthesia start time |354 |
| | | | |
| | |Patient taken to OR via stretcher, alert, oriented x3 for primary cesarean section due to NRFHT. | |
| | |Doctors Xxxx, Qadri, Anesthesiologist Dr. Xxxx and Ahmad present to administer anesthesia. Patient assessed on | |
| | |transfer to OR table, positioned for administration of Combined Spinal Epidural (CSE). | |
| | | | |
| | |Agents: Demerol, Pitocin | |
| | | | |
| | |CSE administered. Patient lay down, SCDs applied to lower legs. Foley catheter inserted 16 draining clear yellow | |
| | |urine outputs, _____ applied to right thigh. | |
| | |Tagamet 300mg, Reglan 10mg, Bicitra 30mg. | |
| | | | |
| | |@1523 hrs: Ancef 2gm IV. | |
| | |@1529 hrs: Surgery start time | |
|12/30/YYYY | Xxxx, M.D. |@1529 hrs: Operative report for primary cesarean section: |374-375, |
| | |Pre-operative and post-operative diagnoses: Un-reassuring fetal heart rate tracing, thick meconium at 36 weeks |354 |
| | |gestation. | |
| | | | |
| | |Procedure: Primary cesarean section. | |
| | | | |
| | |Procedure: Patient was taken to the operating room, placed in a dorsal supine position. Adequate level of spinal | |
| | |anesthesia was obtained and the abdominal area was prepped and draped in a sterile fashion. A Pfannenstiel skin | |
| | |incision was made, which was taken down to parietal peritoneum using sharp dissection. A bladder flap was created | |
| | |and a low-transverse uterine incision was performed. Baby was delivered from the vertex presentation, Right Occipito| |
| | |Posterior (ROP) position without difficulty and handed to the Pediatricians in attendance. A segment of cord was cut| |
| | |for cord pH determination and cord blood was obtained for cord blood banking. | |
| | | | |
| | |The placenta was delivered without any evidence at placental separation and sent for specimen. The uterine incision | |
| | |was closed in 2 layers of 0 Vicryl in a continuous interlocking stitch with a second layer imbricating the first. | |
| | |Adequate hemostasis was noted. The bladder flap was then sutured to the uterine serosa using double 0 chromic in a | |
| | |continuous stitch. Instrument, lap, and sponge count was correct. The abdominal gutters were cleansed of clots and | |
| | |debris. Thick meconium was noted at delivery. The peritoneum was closed using 0 chromic in a continuous stitch. | |
| | |Fascia was closed using 0 Vicryl in a continuous stitch in halves and the skin was closed using triple 0 Monocryl in| |
| | |a subcuticular stitch. A sterile dressing was applied. The patient was taken to the recovery room. Urine was clear. | |
|12/30/YYYY | Xxxx, M.D. |L&D delivery report: |429 |
| | |Delivery time: 1531 hrs | |
| | |Number of babies: Singleton | |
| | |Vaginal/C-section: C-section | |
| | |Type of cesarean delivery: Primary C-section | |
| | |Indication for C-section: Abnormal FHR tracing | |
| | |Type of incision: Low transverse C-section. | |
| | |Estimated blood loss: 750mL | |
| | |Anesthesia: Spinal | |
| | | | |
| | |Method of placenta delivery: Manual removal | |
| | |Nuchal cord: Present | |
| | |Additional procedures: None | |
| | |Additional comments: Thick meconium, nuchal cord noted. Cord pH: 7.37/7.44. Cord blood for cord blood banking. | |
| | |APGAR: 3/5/5. Neonatologist present at delivery. | |
| | | | |
| | |Was pediatrician in attendance at delivery: Yes | |
|12/30/YYYY |ABC Hospital |Cord blood gas report: |384 |
| | |Collected time: 1552 hrs | |
| | | | |
| | |Arterial | |
| | |Venous | |
| | | | |
| | |Base excess | |
| | |1.1 | |
| | |-1.8 | |
| | | | |
| | |pH | |
| | |7.37 | |
| | |7.44 | |
| | | | |
| | |pCO2 | |
| | |44.6 | |
| | |29.8 | |
| | | | |
| | |pO2 | |
| | |22.1 | |
| | |33.1 | |
| | | | |
| | |O2 saturation | |
| | |34.2 | |
| | |67.3 | |
| | | | |
| | |HCO3 | |
| | |26.3 | |
| | |20.6 | |
| | | | |
|12/30/YYYY | |Neonatal ICU admission for respiratory distress: Illegible notes |23-25 |
| | |Initial course: Baby delivered floppy, not breathing, nuchal cord noted. Heart rate less than 100. To _________, | |
| | |intubated with Endotracheal Tube (ETT). Suctioned below the cord _____ meconium. Recovered PPV with bag of mask, | |
| | |heart rate improved but no spontaneous respirations/ETCO2/irregular breaths). Re-intubated PPV, continued via ETT | |
| | |______ | |
| | | | |
| | |Physical exam: | |
| | |Weight: 2650 grams (10-50%) | |
| | |Length: 50cm (90%), head circumference: 33.5 cm (50%) | |
| | | | |
| | |Glucose: 63 | |
| | | | |
| | |Vitals: Heart rate: 155, RR: 34, BP: 75/42, MAP: 53, temperature: 97.9 | |
| | | | |
| | |General appearance: Pink (on ventilation), floppy, no active movements appear ______, Anterior Fontanelle Open and | |
| | |Flat (AFOF) | |
| | | | |
| | |Eyes: No A/C | |
| | | | |
| | |Ears: Clean | |
| | |Mouth and throat: Intubated via mouth, palate intact. | |
| | |Neck: No mass | |
| | |Clavicles: Intact bilaterally. | |
| | |Lungs: On ventilation, good air entry bilaterally. | |
| | |Heart: S1S2, regular rate and rhythm. No murmurs. | |
| | | | |
| | |Abdomen: Soft, non-distended, _____ 3 cm. | |
| | |Extremities, hip exam and pulses: PS+2 bilaterally. No active movements. Negative Ortolani/Barlow. | |
| | |Spine: Straight. No deformities. | |
| | | | |
| | |Genitalia: Testes descended bilaterally. | |
| | |Neurological: Floppy, not moving. | |
| | |Skin: Small bruise over right shoulder. | |
| | | | |
| | |Gestational age: 36 | |
| | | | |
| | |Impression: | |
| | |36 weeker, newborn | |
| | |Prenatal respiratory depressions | |
| | |Rule out meconium aspiration – Presumed sepsis. | |
| | | | |
| | |Plan: | |
| | |Admit to NICU. Vital signs per protocol. Monitor In’s and Out’s. | |
| | |Nil per oral. IVF D10W at 80ml per kg. Ampicillin, Gentamicin | |
| | | | |
| | |Therapeutic: Complete Blood Count (CBC)/differential/C-Reactive Protein (CRP)/blood culture/Arterial Blood Gas | |
| | |(ABG)/chest X-ray. | |
| | | | |
| | |Discussion with NICU attending team. | |
|12/30/YYYY |ABC Hospital |Respiratory assessment: (Anna Pertsovsky, RRT) |257-258, |
| | |Ventilator/BiPAP: 30% |214-215 |
| | |Neonatal ventilator mode: SIMV + PS | |
| | |PEEP: 5cm H2O | |
| | |Pressure support: 8 | |
| | |MAP: 9 | |
| | |Peak inspiratory pressure : 18 cm H2O | |
| | |Oxygen saturation: 100%. | |
| | |Apnea interval: 10 sec | |
| | | | |
| | |Newborn baby C-section delivery 36 weeks gestation meconium aspiration, admitted to NICU. Patient intubated with | |
| | |Endo Tracheal Tube (ETT) 3.5 in OR. Patient put on ventilator. Bilateral breath sounds are equal. | |
| | |*Reviewer’s comment: The intubation record is not available for review. | |
| | | | |
| | |Assessment: (Xxxxx, R.N., Xxxx, R.N.) | |
| | |Vitals: | |
| | |Temperature: 97.9, RR: 34, SpO2: 100%, systolic BP: 72, diastolic BP: 42, MAP: 53, glucose heel stick: 63 | |
| | | | |
| | |Neonatal Infant Pain Scale (Nips): | |
| | |Face: Relaxed muscles, neutral expression | |
| | |Cry: Quiet, not crying. | |
| | |Breathing: Relaxed. | |
| | |Arms: Relaxed, no muscular rigidity, occasional random. | |
| | |Legs: Relaxed, no muscular rigidity. | |
| | |State of arousal: Sleeping/awake, quiet, peaceful. | |
| | |Pain score: 0. | |
|12/30/YYYY |Xxxxxx, M.D. |X-ray chest: |128-129 |
| | |History: Respiratory distress. | |
| | | | |
| | |Findings: | |
| | |Lines/tubes: Endotracheal tube terminates 7 mm above the carina. | |
| | |Lungs and pleura: There is a hazy opacity at the right upper lobe incomplete characterize on the current study. | |
| | |There is no pleural effusion or pneumothorax. | |
| | |Heart and mediastinum: The heart and the mediastinum are unreable for age. | |
| | |Bones: The thoracic skeleton is unreable for age. | |
| | | | |
| | |Impression: Hazy opacity overlying the right upper hemithorax could represent atelectasis versus consolidation. | |
|12/30/YYYY | |Attending notes: Illegible notes |332 |
| | |Received call from patient this morning, complaining of cramping for several days and discharge. Instructed patient | |
| | |to go to L&D triage for evaluation. Rule out possible dehydration and consequent PTL. Patient presented to triage in| |
| | |the early afternoon. Initial evaluation showed thick meconium, vertex presentation. | |
| | | | |
| | |Patient states she had broken her water after having spoken to me. Patient was placed on monitor. She was 3cm | |
| | |dilated at 1425 hours and received a call from Dr. Xxxx (PGY2) status. FHR tracing was minimal variability with | |
| | |contractions every 4-5 minutes. Resuscitation efforts (Increased IVF, oxygen by face mask, left lateral position) | |
| | |initiated. OR was put on stand-by with cesarean section planned unless tracing improved. | |
| | | | |
| | |I arrived at the hospital at 1505 hours. FHR tracing still with minimal variability contractions every 4-5 minutes, | |
| | |episodic late decelerations (mild). Patient examined, 5cm, 100 %, ____ thick meconium. Patient was brought to OR. | |
| | |Spinal anesthesia given at 1515 hours, incision at 1529 hours and delivery at 1531 hours. | |
| | | | |
| | |Neonatologist was called and in OR along with Pediatrician. Baby delivered from the vertex presentation, ROP | |
| | |position, APGAR 3/5/5, cord pH, arterial/venous: 7.37/7.44, base excess, arterial/venous: 1.1/-1.8. Cord blood was | |
| | |obtained for private banking. No evidence of placental abruption (placenta had separated partially during and cord | |
| | |blood collection but no retroplacental clot present). Patient tolerated surgery well. Baby taken to NICU in stable | |
| | |condition. Discussed with patient family course of events in detail. | |
|12/30/YYYY | |PGY2 notes: |26 |
| | |Chest X-ray examined by me and Dr. XXX. The tip of ET tube looks to be located close to carina (10 cm at upper lip).| |
| | |Reposition of the tube indicated. Tube repositioned to 9.5 cm (pulled back by 0.5cm) and taped to Neoban. No changes| |
| | |in baby’s vital signs/respiratory status. | |
|12/31/YYYY | |NICU Attending progress notes: Intubated in OR. Noted to be significantly hypotonic. On ventilation with weaning |29 |
| | |possible until today morning. Intermittently breathing only with ventilation. One gasping respiratory effort also | |
| | |noted. | |
| | | | |
| | |NPO: On IV fluids | |
| | |On antibiotics for presumed sepsis. X-ray not suggestive of aspiration. | |
| | | | |
| | |Physical examination: | |
| | |BW: 2650gm | |
| | |Weight: 2650gm | |
| | |SpO2: 96%, heart rate: 132, RR: 35, BP: 67/48, MAP: 55, temperature: 97.6 | |
| | | | |
| | |Incubator. FiO2: 0.21. | |
| | |Extremities: Tone increased on all extremities. | |
| | |Neuro: Hypotonia of neck and trunk. | |
| | | | |
| | |Assessment/plan: | |
| | |Preterm infant with hypotonia at birth. Wean ventilator settings, evaluate if able to breathe spontaneously | |
| | |Head ultrasound, neuro consult | |
| | |TPN tonight, Basic Metabolic panel (BMP), Complete Blood Count (CBC) evening | |
|01/01/YYYY | |NICU Attending progress notes: Illegible notes |31 |
| | |Baby was on SIMV ventilator with alkalotic blood gases. Baby had no breathing _____ until weaned on ventilator to | |
| | |achieve residual gases. Nil per oral. On Ampicillin and Gentamicin, blood culture negative for 30 hours. | |
| | | | |
| | |Physical examination: | |
| | |BW: 2650gm | |
| | |Weight: 2640gm | |
| | |Weight change: Decreased by 10gm | |
| | |Spo2: 99%, heart rate: 153, RR: 59, BP: 63/46, MAP: 52 | |
| | |HEENT: No tongue fasciculations, jaw open, no gag reflex. | |
| | |Genito Urinary (GU): Undescended testes. | |
| | |Neuro: ______, severe hypotonia of trunk and extremities. Tight spasms on right hand. No clonus. Reacts but does not| |
| | |withdraw to pain. | |
| | | | |
| | |Labs (12/31/YYYY): | |
| | |Sodium: 135, chloride: 102, BUN: 13, glucose: 81, potassium: 5.0, carbon dioxide: 19, creatinine: 0.8, calcium: 8.6,| |
| | |neonatal bilirubin: 3.5, direct bilirubin: 0.2 | |
| | | | |
| | |Assessment/plan: | |
| | |Extubate to CPAP or ______. | |
| | |Start feeds later if tolerating CPAP | |
| | |Gentamicin trough | |
| | |Neurology consult. Suspect LMN or muscular dystrophy | |
|01/01/YYYY |Xxxxx, M.D. |Pediatric Neurology consultation for hypotonia: |106-109 |
| | |Birth: Reviewed. | |
| | |Thick meconium suctioned below cords. The baby was intubated in the Delivery Room (DR) and extubated this morning. | |
| | |There is no history of seizure-like activity. | |
| | | | |
| | |Physical examination: | |
| | |Head circumference: 34cm (75-90%). Stable vital signs, on CPAP. | |
| | |Oro-gastric tube in place. The baby had ed expiratory stridor and mild inspiratory stridor. There were no dysmorphic| |
| | |features or deformities. There was no muscle wasting. The anterior fontanel was open and flat. There were no | |
| | |neurocutaneous stigmata. There was no heart murmur. The abdomen was soft and non-tender, without masses or | |
| | |hepatosplenomegaly. | |
| | | | |
| | |Neurologic exam: | |
| | |Mental status: The baby was sleeping and only moved minimally, even with vigorous stimulation. He didn’t cry at all.| |
| | |No seizure-like activity was seen. | |
| | | | |
| | |Cranial nerves: The pupils were equal and reactive to light. Extra-ocular movements were full. I couldn’t visualize | |
| | |the fundi. Facial sensation was grossly intact to light touch. There was no asymmetry of the nasolabial fold or | |
| | |palpebral fissure, but he appeared to have bilateral facial weakness with constantly open mouth. There was no | |
| | |response to the sound of a loud rattle. I couldn’t elicit a gag reflex. There was no drooling. Head-turning was | |
| | |strong bilaterally. Tongue was midline with full range of motion. | |
| | | | |
| | |Motor: He had severe, diffuse hypotonia with very poor arm flexion and severe head lag on traction. Strength could | |
| | |not be assessed adequately because of poor voluntary movements, but he appeared to have at least anti-gravity | |
| | |strength. Movements were symmetrical. There were no fasciculations, tremors or other involuntary movements. | |
| | | | |
| | |Sensory: The sensory examination was intact to light touch. | |
| | | | |
| | |Deep Tendon Reflexes (DTRs): The deep tendon reflexes were normal and symmetrical other than bilaterally depressed | |
| | |knee jerks. I couldn’t elicit a Moro reflex. There was no clonus. | |
| | | | |
| | |Cerebellar: There was no nystagmus. | |
| | | | |
| | |Clinical impression: The boy is with severe, diffuse hypotonia, absent gag reflex and possible bilateral facial | |
| | |weakness. He has depressed knee jerks, but normal reflexes otherwise. Strength may be diminished. These findings | |
| | |could be due to a neuromuscular disorder, a congenital brainstem anomaly or a genetic disorder. | |
| | | | |
| | |Diagnoses: Hypotonia. Rule out brainstem anomaly. | |
| | | | |
| | |Plan: MRI brain, non-contrast. CK. Consider performing chromosomal microarray, DNA myotonic dystrophy and muscle | |
| | |biopsy. If findings persist on follow-up and MRI scan of the brain isn’t diagnostic. | |
|01/02/YYYY | |Procedure report for lumbar puncture: |35 |
| | |Pre-procedure and post-procedure diagnoses: Rule out sepsis, respiratory distress and hypotonia. | |
| | | | |
| | |Procedure: Lumbar puncture. | |
| | | | |
| | |Pathology/samples sent to lab: Cerebro Spinal Fluid (CSF). | |
| | | | |
| | |Patient’s condition: Stable. | |
|01/02/YYYY | |NICU Attending progress notes: Illegible notes |37-40 |
| | |Thick meconium and low APGAR score. Group B streptococci (GBS) positive. Hypotonic, neuro consult done. Gentamicin | |
| | |trough was high. Gentamicin held. On Total Parenteral Nutrition (TPN). | |
| | | | |
| | |Physical examination: | |
| | |Birth Weight (BW): 2650 gm | |
| | |Weight: 2600 gm | |
| | |Weight change in 24 hours: Decreased by 40 gm | |
| | |Oxygen saturation: 97% | |
| | |Heart rate: 145 | |
| | |RR: 61, BP: 55/39, MAP: 41, temperature: 98, FiO2: 21%, Nasal Continuous Positive Airway Pressure Treatment (NCPAP):| |
| | |21/5 | |
| | | | |
| | |Neuro: Decreased tone in lower ______. | |
| | |Otherwise unreable. | |
| | | | |
| | |Labs (01/01/YYYY): | |
| | |Sodium: 143, chloride: 108, BUN: 17, glucose: 76, potassium: 4.8, carbon dioxide: 21, creatinine: 0.7, calcium: 9.1 | |
| | | | |
| | |Nil Per Oral (NPO). | |
| | | | |
| | |Output: 3 cc/kg | |
| | |Stool x3 | |
| | | | |
| | |Assessment/plan: | |
| | |MRI and CK in next 2-3 days. If tone did not improve, followed by microarray, start feeding 5ml of _______. | |
|01/02/YYYY | |Attending addendum: |38 |
| | |Informed by OB that maternal culture and sensitivity of placenta is growing gram negative rods, to be identified. | |
| | | | |
| | |Baby already on antibiotics/Ampicillin. | |
| | |Gentamicin: Will follow levels and continue. Blood culture and sensitivity so far negative. | |
| | | | |
| | |Plan: Repeat Gentamicin level and consider further therapy after that. | |
|01/03/YYYY |Xxxx, M.D. |Echocardiogram: |110 |
| | |Reason for study: Tachypnea. | |
| | | | |
| | |Interpretation: Small Patent Foramen Ovale (PFO) left to right shunt. Mild Right Ventricular Hypertrophy (RVH). Good| |
| | |Left Ventricular (LV) function. | |
|01/03/YYYY | |Cardiology consultation to rule out cardiomyopathy: |53 |
| | |Cardiology evaluation for history of tachypnea. | |
| | | | |
| | |On examination, fair, afebrile, pink | |
| | |Cardiac: S1S2 | |
| | |Respiratory: Air entry fair on oxygen by nasal cannula. | |
| | | | |
| | |Assessment/plan: 2D echo reviewed. No interventions and follow-up in 3 months. | |
|01/03/YYYY |ABC Hospital |NICU progress notes: Illegible notes |41 |
| | |Patient is also with issue of tremulousness/myoclonic movements. Questionable seizure activity. Initial report of | |
| | |placental culture with gram negative rods, but no growth for 2 days. No sepsis or Herpes. Status post LP yesterday. | |
| | |Extubated on 01/01/YYYY, now on NCPAP. HUS pending, needs MRI/CT today. | |
| | | | |
| | |Physical examination: | |
| | |Birth weight: 2650 gm | |
| | |Weight: 2530 gm | |
| | |Weight change in 24 hours: Decreased by 30 gm | |
| | |SpO2: 99%, heart rate: 162, RR: 63, BP: 70/45, MAP: 54 | |
| | |FiO2: 63, NCPAP: +6 | |
| | | | |
| | |Neuro: Significant head lag and hypotonia. Positive tremulousness. | |
| | |Otherwise unreable. | |
| | | | |
| | |Labs: | |
| | |Creatine Kinase (CK): Pending | |
| | |Ammonia: 69, | |
| | |CSF: No WBC, glucose: 51, protein: 162 | |
| | |Glucose: 102, WBC: 3.9, hematocrit: 49.2, platelets: 102 | |
| | | | |
| | |Assessment/plan: | |
| | |Fluid, Electrolytes, And Nutrition (FEN) and GI: Advance to 6 cc x8. Monitor for tolerance. Continue TPN for TF/20 | |
| | |BMP in the morning. | |
| | | | |
| | |Heme: Bilirubin in the morning. CBC in the morning to re-evaluate _____ | |
| | |Respiratory: Wean off NCPAP. Continuous monitor. | |
| | |Neuro: MRI today. EEG today. Repeat CK. Questionable seizure activity. | |
|01/03/YYYY |Xxxxxx, M.D. |Ultrasound neonatal brain: |127-128 |
| | |History: Suspected intracranial hemorrhage. | |
| | | | |
| | |Impression: Findings compatible with grade 3 germinal matrix hemorrhage including hemorrhage at the bilateral | |
| | |caudo-thalamic groove, intraventricular hemorrhage of both lateral ventricles and moderately distended third and | |
| | |lateral ventricles. | |
|01/03/YYYY |Xxxxx, M.D. |MRI brain without contrast: |126-127 |
| | |Reason: Rule out brain abnormality. Neonatal head ultrasound demonstrated intracranial hemorrhage. Gestational age | |
| | |36, APGAR 3/5. | |
| | | | |
| | |Comparison: Comparison is made with the neonatal head ultrasound performed earlier on the same date at 1037 hours. | |
| | | | |
| | |Findings/impression: The hemorrhage described on the neonatal head ultrasound performed earlier on the same date is | |
| | |not appreciated on the current examination. There is re-demonstration of mild enlargement of the lateral and third | |
| | |ventricles. The parenchymal morphology and signal intensity appears within normal range for the gestational age. | |
| | |There is no evidence for an intracranial mass. Diffusion weighted images demonstrate no restricted diffusion to | |
| | |suggest an acute infarct. Further assessment and blow-up with head ultrasound is recommended. | |
|01/04/YYYY |ABC Hospital |Urine culture: |125 |
| | |Collected date: 01/02/YYYY | |
| | |Final result: No growth. | |
|01/04/YYYY | |@0940 hrs: NICU Attending progress notes: Illegible notes |45-46 |
| | |History: Reviewed. | |
| | | | |
| | |MRI yesterday does not detect hemorrhage, but instead acute infarct. Jittery movements, usually with stimulation. No| |
| | |seizures. | |
| | | | |
| | |Physical examination: | |
| | |Birth weight: 2650 gm | |
| | |Weight: 2680 gm | |
| | |Weight change: Increased by 150 gm | |
| | |SpO2: 100%, heart rate: 173, RR: 62, BP: 71/41, MAP: 51, temperature: 98.8 | |
| | | | |
| | |Neuro: Moves extremities in provocation, but little spontaneous movements. Eyes closed, not alert, delayed gag. | |
| | |Otherwise unreable. | |
| | | | |
| | |Labs: | |
| | |WBC: 4.8, hemoglobin: 15.4, hematocrit: 43.8, platelet: 322 | |
| | |Sodium: 138, chloride: 104, BUN: 23, glucose: 87, potassium: 4.3, creatinine: 0.4, carbon dioxide: 20 | |
| | | | |
| | |Assessment/plan: | |
| | |FEN/GI: Increase 18 x8. Monitor for tolerance. Supplement with TPN for TF/25. | |
| | |Heme: PT value within normal limits on this CBC. Follow-up heme regarding _______. | |
| | |Respiratory: NCPAP, wean as tolerated. | |
| | | | |
| | |Neurologic: Video Electro Encephalo Gram (VEEG) to be done today. Follow-up results. Follow-up with Dr. Schubert | |
| | |regarding head ultrasound and MRI results. | |
| | | | |
| | |SOC: Spoke to mother and maternal grandmother x 30 minutes, yesterday regarding head ultrasound results. Disclose | |
| | |_______. | |
|01/04/YYYY | |@1700 hrs: NICU Attending addendum notes: Illegible notes |46 |
| | |MRI does not show evidence of infarct. Rectified status update to parents who understand the _____ in my error. Does| |
| | |not change current status of severe abnormal neurologic findings. Plan to continue work-up neuromuscular etiologies | |
| | |of hypotonia. | |
|01/04/YYYY | |NICU progress notes: Illegible notes |51 |
| | |New born depression/hypotonia. On NIMV CPAP. Patient _____ neuro checks. | |
| | | | |
| | |Patient will breathe easy on room air. Infection - _____ tone and activity. | |
| | | | |
| | |Assessment/plan: | |
| | |Continue CPAP | |
| | |Advance feeds OGT | |
| | |Discontinue antibiotics tomorrow. | |
| | |MRI and video EEG | |
|01/04/YYYY-01/05/Y|Xxxxx, M.D. |Video Electro Encephalogram monitoring: |112-114 |
|YYY | |Reason for EEG monitoring: Continuous video EEG monitoring was performed because of the persistently altered mental | |
| | |status. | |
| | | | |
| | |Clinical and EEG events: Jerks of the hands, spontaneous clonic movements of the extremities are not accompanied by | |
| | |EEG changes other than muscle artifacts. | |
| | | | |
| | |Summary of EEG findings: Burst suppression pattern. No sleep wake differentiation. Clonus and myoclonic jerks of the| |
| | |extremities are without EEG changes other than artifacts. No electrographic seizures. | |
| | | | |
| | |No seizure or epilepsy diagnoses. | |
| | | | |
| | |Clinical correlation and recommendations: The data obtained in this study are consistent with a severe, diffuse | |
| | |encephalopathy. The clinical events consisting of myoclonic jerks and clonic movements of the extremities are not | |
| | |epileptic in nature. No electrographic seizures were recorded. This EEG pattern is associated with a poor prognosis,| |
| | |particularly if persistent. Repeat studies are recommended. | |
|01/05/YYYY | |NICU progress notes: |47-48 |
| | |Video EEG: Reviewed. | |
| | | | |
| | |Physical examination: | |
| | |BW: 2650 gm | |
| | |Weight: 2850 gm | |
| | |Weight change: Increased by 170 gm | |
| | |SpO2: 100%, heart rate: 163, RR: 67, BP: 74/46, MAP: 56, temperature: 98.3 | |
| | | | |
| | |NCPAP: 21/5, discontinued. | |
| | | | |
| | |Head, Eyes, Ears, Nose and Throat (HEENT): No tenting of mouth. | |
| | | | |
| | |Neuro: Delayed gag. Not alert. Positive brisk reflexes in upper extremity ultrasound. | |
| | |*Reviewer’s comment: The upper extremity ultrasound is not available for review. | |
| | | | |
| | |Labs: | |
| | |WBC: 8.2, hemoglobin: 14.7, hematocrit: 41.7, platelet: 253 | |
| | |CK: Pending | |
| | | | |
| | |Assessment/plan: | |
| | |Genetics: Consent for genetic testing of myotonic dystrophy, Prader Willi , etc. | |
| | |Neuro: Follow-up video EEG final results, family meeting tomorrow with Neurologist. Ophthalm exam next week. | |
| | |Infectious Disease (ID): Discontinue antibiotics, continue Acyclovir. | |
| | |FEN/GI: Advance feeds to 36 x8, monitor for tolerance. Discontinue TPN. | |
| | |_____: Follow-up placental pathology. | |
|01/06/YYYY | |@1027 hrs: NICU Attending progress notes: Illegible notes |49-52 |
| | |Late preterm male infant with encephalopathic features and newborn depression initial brain MRI, no clinical or | |
| | |electrical seizure activity. PE increasing with increased tone in upper and lower extremities. Still significant | |
| | |truncal hypotonia or head lag. Rule out Herpes Simplex Virus (HSV), on Acyclovir. | |
| | | | |
| | |Normal ammonia. No metabolic/lactic acidosis. | |
| | | | |
| | |Physical examination: | |
| | |BW: 2650 gm | |
| | |Weight: 2770 gm | |
| | |Weight change: Decreased by 80 gm | |
| | |SpO2: 95%, heart rate: 179, RR: 70, BP: 68/38, MAP: 49, temperature: 98.7, FiO2: 0.21 | |
| | | | |
| | |Skin: Mild body edema. | |
| | |Genito urinary (GU): Testes descended bilaterally | |
| | |Extremities: Bilateral clinodactyly | |
| | |Neuro: Excessive _____ resulting in clonus, brisk DTRs x4. Increase tone in extremities. No focus of eyes. Eyes | |
| | |closed. Significant head lag. Gag only with vigorous stimulation. Little spontaneous movements. | |
| | | | |
| | |Assessment/plan: | |
| | |ID: Discontinue Acyclovir | |
| | |Genetics: Evaluate for _____ myotonic dystrophy, etc | |
| | |FEN/GI: Continue current feeding regimen. | |
| | |Neuro: Continuous monitoring. _______ x 2 per telephone report. To do hearing screen today. Ophthalmo exam next | |
| | |week. | |
|01/06/YYYY | |@1510 hrs: NICU Attending progress notes: Illegible notes |52 |
| | |Multidisciplinary rounds with Dr. Schubert and me, parents, maternal grandmother (MGM) and social worker. Reviewed | |
| | |MRI findings, EEG results, and clinical exam with parents and MGM. Discussed plans of further metabolic roles and | |
| | |genetic work-up. Discussed possible transfer to outside hospital (Eg. XYZ ), if metabolic disorder appears more | |
| | |likely. Spoke to Metabolic fellow regarding _____. Will draw simultaneous plasma and CSF glycine on Monday and _____| |
| | |from XYZ to pick up. Instructions approved. Will further discuss need for transfer on Monday. | |
|01/06/YYYY | |Genetics consultation: Illegible notes |54-55 |
| | |History reviewed and discussed with Attending and Resident. | |
| | | | |
| | |On PE today, possibly mild dystrophism with suggestive of short _____ fissure and Increased skin ___ of neck. PE | |
| | |limited due to _____. Bilateral clinodactyly with ___ cracks on palms and fingers, but findings are different and | |
| | |possibly extend suggestive of _______. | |
| | | | |
| | |______ Small for size, _____ dorsum of feet, with increased tone in upper and lower extremities, elbow mildly | |
| | |contracted increased reflexes. 2-3 _____ suggestive of ______. 2-3 toe mild syndactyly suggestive of stage 4. ___ | |
| | |head lag. _____ tube in place. Nasal oxygen. Baby does not ____ hardly and has tremulousness intermittently ____ | |
| | |absent _____ changing time over time. Generalized hypotonus. ______ mild dystrophy. _______. Present with tone, | |
| | |switch to increased tone is not characteristic. Rule out metabolic/_______/chromosomal. | |
| | | | |
| | |Recommendations: ______, quantitative amino acid plasma and CSF, DNA testing for male RETT, chromosomal array, | |
| | |herpes I, II, VI in CSF, ____ fatty acids. | |
|01/06/YYYY |ABC Hospital |CSF culture: |125 |
| | |Collected date: 01/02/YYYY | |
| | |Final result: No growth | |
|01/06/YYYY |ABC Hospital |Blood culture: |126 |
| | |Collected date: 12/30/YYYY | |
| | |Final result: No growth | |
|01/06/YYYY |Xxxxx, M.D. |Pediatric Neurology follow-up consultation for hypotonia: |107-109 |
| | |The baby’s condition has deteriorated. He remains extremely lethargic and hypotonic. He requires intermittent nasal | |
| | |CPAP to maintain oxygenation. He has been having spontaneous clonus of the extremities. He has severe feeding | |
| | |problems; although he is attempting to suck a little bit. No seizure-like activity has been noted. | |
| | | | |
| | |Physical examination: | |
| | |Head circumference: 34cm, stable vital signs. On nasal CPAP | |
| | |Oro-gastric tube in place. There were no neurocutaneous stigmata. There was no heart murmur. The abdomen was soft | |
| | |and non-tender. Without masses or hepatosplenomegaly. | |
| | | | |
| | |Neurologic exam: | |
| | |Remains unchanged from 01/01/YYYY, except for: | |
| | |Motor: He had severe truncal hypotonia with very poor arm flexion and severe head lag on traction. He had | |
| | |spontaneous clonus of all extremities. | |
| | | | |
| | |DTRs: Spontaneous clonus of the extremities. | |
| | | | |
| | |Labs (01/02/YYYY): Reviewed. | |
| | |Video EEG, MRI and head ultrasound: Reviewed. | |
| | | | |
| | |Clinical impression: This boy is with lethargy, severe, diffuse hypotonia, depressed gag reflex, bilateral facial | |
| | |weakness and spontaneous clonus. MRI scan of the brain shows diminished myelination of the white matter and mild | |
| | |ventriculomegaly. There is no evidence of intracranial hemorrhage or anoxic encephalopathy. Continuous video EEG | |
| | |monitoring shows a burst suppression pattern. There is no metabolic acidosis, ketosis, hyperammonemia or hepatic | |
| | |dysfunction. | |
| | | | |
| | |The differential diagnosis includes: Non-ketotic hyperglycinemia, Male Rett syndrome, Maple syrup urine disease can | |
| | |present this way, but should have been detected on the newborn screen, mitochondrial disorder such as a respiratory | |
| | |chain detect and pyridoxine deficient epilepsy, unlikely without clinical seizures. | |
| | | | |
| | |Diagnoses: Neonatal encephalopathy. Rule out hereditary degenerative disease. | |
| | | | |
| | |Plan: | |
| | |Please repeat Lumbar Puncture (LP) and send Cerebro Spinal Fluid (CSF) for cell count, glucose, protein, lactate and| |
| | |glycine (with simultaneous plasma glucose, lactate and glycine) | |
| | |DNA Methyl-CpG-Binding Protein (MECP2) (RETT syndrome) | |
| | |Chromosomal microarray/Comparative Genomic Hybridization (CGH) | |
| | |Free and total carnitine, acylcarnitine profile | |
| | |Urine organic acids | |
| | |Consider performing muscle biopsy for a mitochondrial disorder, if CSF studies are not diagnostic | |
| | |Repeat continuous video EEG monitoring in 2-3 weeks | |
| | |Repeat MRI scan of the brain in 1-2 months | |
| | |Findings and recommendations were discussed at length with the baby’s parents, (including high risk of severe | |
| | |disability, possibly even death and need for further testing to make a diagnosis) | |
|01/06/YYYY | |NICU on-call Attending notes: |52 |
| | |Patient is transferred to XYZ medical center for metabolic work-up and management. | |
|01/06/YYYY | |Discharge assessment: Illegible notes |22 |
| | |General: Little spontaneous movements. | |
| | |Skin: Mild bodily edema. | |
| | |Head, fontanelle, sutures: AFOF | |
| | |Eyes: No discharge. | |
| | |Ears, nose, mouth and palate: Within normal limits. | |
| | |Neck. Thorax: Supple. | |
| | |Lungs: Clear to auscultation bilaterally. | |
| | |Heart: Regular rate and rhythm, no murmur. | |
| | |Abdomen: Soft, non-tender, non-distended. Positive bowel sounds. | |
| | |Umbilicus: Dried stump. | |
| | |Genitalia, anus: Testes descended. | |
| | |Spine: Within normal limits. | |
| | |Extremities: Brisk DTRs x4 | |
| | |Femoral pulses: +2 bilaterally. | |
| | |Hips: No Barlow’s/Ortolani test | |
| | | | |
| | |Weight: 2770 gm | |
| | | | |
| | |*Reviewer’s comment: The discharge summary is not available for review. | |
|01/08/YYYY |ABC Hospital |Blood culture: |126 |
| | |Collected date: 01/02/YYYY | |
| | |Final result: No growth. | |
|01/21/YYYY |Xxxx, M.D. |Pathology report: |386-388 |
| | |Collected date: 12/30/YYYY | |
| | | | |
| | |Pre-operative diagnoses: G1P0; Meconium stained amniotic fluid; APGAR score: Low | |
| | | | |
| | |Specimen collected: Placenta, cord, and membranes. | |
| | | | |
| | |Diagnosis: | |
| | |389 grams trimmed, 25th-50th percentile for 36 weeks gestation, birthweight not specified. Gross green meconium | |
| | |discoloration reported of membranes only, meconium passage less common preterm, and question clinical correlation. | |
| | | | |
| | |Umbilical cord insertion velamentous. Evidence of acute intra-amniotic infection not appreciated. Prominent chronic | |
| | |marginating chorio deciduitis. | |
| | | | |
| | |Villous histology generally consistent with acceleration of villous maturation for stated gestational age with | |
| | |fibrosis reduced distal capillary networks and villous diameters with increased syncytial basophilia. | |
| | | | |
| | |Infarct, subacute to remote with prominent regional malperfusion-type changes. Intervillous thrombus, laminated and | |
| | |more recent with peripheral villous compression and subjacent chronic decidual inflammation including basal decidual| |
| | |plasma cells and anchoring villitis and local avascular villi. | |
| | | | |
| | |No villous evidence of direct immune mediated injury. No evidence of overall chronic uteroplacental “insufficiency”.| |
|12/30/YYYY-04/16/Y|ABC Hospital |Other related medical records: |
|YYY | |NICU admission flow sheet (Ref. 143-145), Pain assessment (Ref. 145, 142, 130-135), Admission face sheet (Ref. 324), |
| | |Pre-operative and post operative note (Ref. 330-331), Others-operating suite universal protocol/time out form (Ref. 352), |
| | |Peri-operative plan of care (Ref. 355-356), Coding Sheet (Ref. 359-361, 325, 21), Others (Ref. 361), Assessment (Ref. 141, |
| | |245-321), Universal protocol/time out form (Ref. 36), Consent for lumbar puncture (Ref. 57), Social Service Records (Ref. |
| | |134), Plan of care (Ref. 400-410), Authorization (Ref. 102), Discharge Instructions (Ref. 362-372, 393-394), |
| | |Vaccination/Immunization (Ref. 361), Medication orders (Ref. 176-181), Medication administration record (Ref. 181-187), Orders|
| | |(Ref. 188-213), Input / Output Record (Ref. 321-322), HIV prevention and care program test (Ref. 346), MRI/CT study |
| | |requisition (Ref. 59), Nurses admission note (Ref. 27), NICU nursing admission assessment (Ref. 63), OB notes (Ref. 333-336, |
| | |341-343), Delivery room nurse's notes (Ref. 353), flow sheet (Ref. 361, 429-438, 538-557, 64-101, 394-400, 524-538, 136-140), |
| | |Respiratory Therapy (Ref. 147-175, 410-427), Weight-Flow sheet (Ref. 143, 502-522, 140-141, 135, 214-244), Patient Education |
| | |(Ref. 427-429, 146-147), Growth graph (Ref. 60-61), Coding Sheet (Ref. 103-105), Orders (Ref. 438-447, 467-502), Medication |
| | |Administration record (Ref. 447-467), Input / Output Record (Ref. 557-558), Nurses’ notes (Ref. 28, 30-34, 336-337, 42, 44, |
| | |48, 50, 52), Neurology consultation for head ache (Ref. 344-345), Nutrition notes (Ref. 42), Labs-chemistry, hematology (Ref. |
| | |117-125), Labs-chemistry, hematology (Ref. 376-386), Social Service Records (Ref. 130), Obstetrical discharge summary (Ref. |
| | |326-327), Others (Ref. 106, 522-524, 12-13, 58, 361, 388-393, 36), Coding Sheet (Ref. 21), Assessment-newborn nursery record |
| | |(Ref. 22), PACU record (Ref. 539-542), Pathology report (Ref. 560) |
| | | |
| | |*Reviewer’s comment: These records are reviewed and are not captured since all the significant events are already captured, |
| | |hence not included |
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