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In the Newborn nursery, you are asked to come to evaluate a 6 hour old term male infant who is tachypneic to the 70s. The mother had just attempted to breast feed the baby, and reported that he seemed to be latching well. When the nurse came to put him back in the crib she noticed his rapid breathing and brought him in to the nursery. Per the nursing information sheet in the nursery the baby was born at 37 1/7 week to a 25 year old G1P1 mother with no significant past medical history, on no medications. Maternal labs per nurse’s report of prenatal records were: Hep B neg, RPR NR, HIV neg, GBS unknown, Rubella and Varicella non-immune. Infant was born NSVD, with ROM = 17 hours. APGARS 6/9.On PE: VS: Pulse 140, RR 72, P02 95%, BP 70/40, T 37.2Infant is on the warmer, pink with acrocyanosis, in flexed position. No gross deformities or anomalies notedHEENT: AFOF, red reflex b/l, ears normal position & appearance, palate intactNeck: Supple, FROMChest: Mild tachypnea, no retractions, good air entryCor: S1 & S2 heard, 2/6 SEM at LMSB, non-radiating; 2+ inguinal and brachial pulsesAbd: NABS Soft NT/ND no HSM/massGU: Normal male with b/l descended testesMS: Spine without deformity, Hips FROM, neg ort/barlowNeuro: Alert, tone is slightly decreased, normal moro, grasp, babinski reflexesSkin: no rash notedWhat is on your differential right now? What is more and what is less likely? What information might help you? Ddx includes (More common at the top of the list): TTN - this is common, and usually presents within 12 hours. Hypoglycemia – must always consider in a neonate at this age; mild tachypnea may be a sign. SGA, LGA, infants of diabetic mothers are most at risk – but this infant is now 6 hours old and may not have fed well.Sepsis/pneumonia – always have to keep this in mind; we don’t know mother’s full history yet so need to better understand risks. GBS is unknown.Respiratory distress syndrome – this infant is just term at 37 2/7 weeks; if mother was late to care, her dates may be less accurate (most accurate dates are from 8 weeks) and perhaps this is actually a late pre-term infant, with increased risk for RDSMeconium aspiration syndrome – less likely, as just 37 weeks, but important to review birth record for thisCardiac - tachypnea may be sign of cardiac anomalies in the immediate NB period. However, these are usually lesions which cause significant cyanosis, which this baby doesn’t have. The infant’s murmur is likely a PDA, which would not cause significant issues at this point. Inborn errors of metabolism – less likely but should be considered. In this case infant will look sick, DS may be abnormal, tone may be abnormalPersistent pulmonary hypertension of the newborn Pneumothorax – especially if infant needed PPV in the DR (check birth record)What are your next steps? D stickAt this point, obtaining pre- and post-ductal sats would be helpful. Calculate the Kaiser sepsis score (KSS)Further review of prenatal records (if DS and sats are OK, then you have time!) On further evaluation an hour later, the infant is now more tachypneic, with RR in 80s. The PE is significant for increased work of breathing, with some head bobbing and nasal flaring. Pulse ox is still > 95%. The murmur is still present, and unchanged. The remainder of the PE is as the before.Now what are you thinking? What do you want to do now?With worsening respiratory distress, one should put sepsis/pneumonia higher on the list. You should be thinking of a NICU eval/transfer at this point. The KSS will have changed as the infant now looks significantly worse. CBC, blood culture, CXR will be helpful. References: ................
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