In: Nursing
1. Describe at least one deficiency from the example below that was present in the health record and would require a physician query to resolve:
2. Compose a compliant query to physician (75-100 words) to resolve deficiency:
Example
Date of Service: 3/22/2014
Referring Physician: Arleta Rewers, M.D.
Referring Hospital: ED
PCP:
Chief Complaint:
Trouble breathing
Admission Diagnoses:
Respiratory failure
Hypothermia
Rule out serious bacterial infection
Rule out HSV infection
History of Present Illness: This infant was born at 33 6/7 weeks gestation on at 7:56am with a
birth weight of1980g to a 20 year old G3, P1, now 2 mother. Infant is AGA. Prenatal labs include: blood type
AB Positive, antibody screen negative, GBS: unknown, Hep B Status: negative, VDRL non-reactive, rubella
immune, HIV negative, GC/Chlamydia negative. Pregnancy complications: prolonged and preterm ROM.
Maternal Substance Use: None. Medications during pregnancy: PNV, zantac.
Infant was born by spontaneous vaginal delivery with rupture of membranes 2 days prior. Amniotic fluid
was clear, slightly yellow. Labor was uncomplicated. Apgar scores were 7 and 9. Infant was vigorous at
delivery and received resuscitation including brief blow. Post-delivery course was significant for a 16 day
admission to There infant had a 48 hour rule out and was well appearing, on room air (except for a
brief episode on LFNC) and went home on DOL 17 when tolerating full feeds and growing. Has had two PCP
visits since discharge, mother reports good interval weight gain prior to this illness.
Baby has been doing well at home, until 2 days prior to admission. At that time, she developed
congestion, sneezing and cough. She continued to be well appearing and eat well (breast milk 20 kcal via
bottle) and have normal wet diapers and stooling. She had emesis overnight and stopped tolerating anything
by mouth, and having worsening emesis of mostly mucus, this am. She became more sleepy as well, so was
brought to the ED.
ED Course: T 33.4 | HR 153 | RR 22 | BP 69/33 | SpO2 100% on blow by
Per verbal report and review of vitals and labs in chart: Pt noted to have apneic episodes without desaturation
or bradycardia. Was stimulated out of some, and received BVM for others. Due to continued apnea, pt was
intubated, using fentanyl, versed and rocuronium. During the time in the ED, pt had received 40ml/kg in NS
boluses and was receiving another 20ml/kg NS bolus during transport up to the NICU. Blood culture, CBC,
CRP, ESR and BMP sent in ED, along with UA, and urine culture. RVP sent as well. Ampicillin given.
Foreign bodies prior to admission: ET tube and PIV
Medical/Surgical/Family History:
I have reviewed, verified and personally updated the past medical, surgical and birth history.
Pertinent items to this admission include:ex
(MR # Printed by [113902] at 8/7/14 9:31 AM Page 1
History and Physical
H&P Notes (continued)
H&P by Brown, Laura D., M.D. at 3/22/2014 2:14 PM (continued)
Social History:
Barriers to communication: None
Preferred language:
MOC currently lives in a halfway house for theft, possibly. FOC is MOC's current husband, and they live
together with maternal GMOC.
Second hand Smoke:
Does anyone who lives with or cares for the child smoke?No
Did the Mother smoke before/during her pregnancy?No
Medications:
No prescriptions prior to admission
Allergies:
Allergies as of 03/22/2014
•(No Known Allergies)
Review of Systems:
Constitutional: See history of present illness.
HEENT: See history of present illness.
Respiratory: See history of present illness.
Cardiovascular: Negative
Gastrointestinal: See history of present illness.
Genitourinary: Negative
Reproductive/Endocrine: Negative
Musculoskeletal: Negative
Hematology/Lymphatic: Negative
Immune/Allergy/Rheumatologic: Negative
Skin: Negative
Central Nervous: Negative
Physical Exam:
Weight: 2.3 kg (10%)
Height: 44.00cm (0.00%)
OFC: not yet measured
BP 64/32 | Pulse 173 | Temp 36.8 | Resp 32 | Ht 44 cm | Wt 2.3 kg | SpO2 99% on CMV, 50%
General: Paralyzed, sedated on the ventilator
HEENT: normocephalic, atraumatic; anterior fontanelle open, soft, and flat; red reflex present bilaterally, nares
and ear canals patent bilaterally - small amount of clear mucus in nares
Neck: supple
Chest: breath sounds on the ventilator are mostly clear to auscultation bilaterally, mild crackle/wheeze in left
lung field. Good chest rise, good aeration.
CV: regular rate and rhythm, normal S1 and S2, no murmur, rub, or gallop
(MR # Printed by [113902] at 8/7/14 9:31 AM Page 2
History and Physical
H&P Notes (continued)
H&P by Brown, Laura D., M.D. at 3/22/2014 2:14 PM (continued)
Abdomen: soft, nontender, nondistended, hypooactive bowel sounds, no hepatosplenomegaly or mass
Back: no sacral dimples or tufts
GU/Rectal: normal appearing external genitalia
Extremeties: warm, well perfused. Cap refill 2 seconds. Femoral pulses 2+
Neurologic: paralyzed
Skin: no rashes or lesions
Data/Diagnostics Studies:
CBC w/diff
Recent Labs
03/22/14
1115
WBC 5.17*
RBC 3.62
HGB 11.9
HCT 33.7
MCV 93.1*
MCH 32.9
MCHC 35.3
RDW 13.6*
PLTCT 310
MPV 10.9*
SEGS 29.4
LYMPHS 55.1
MONOS 12.8
EOS 2.3
BASOS 0.2
PLTEST NORMAL 150-500,000
CMP
Recent Labs
03/22/14
1115
03/22/14
1345
NA 136 141
K 4.2 4.0*
CL 103 111*
BIC 28 25
BUN 9 9
CRE 0.36 0.34
GLU 174* 73
CA 9.0 9.0
TP -- 4.7
ALB -- 2.6
AGRATIO -- 1.2
BILT -- 1.5*
ALK -- 133
AST -- 22
ALT -- 22
ESR/CRP:
Recent Labs
03/22/14
1115
SEDRATE 12
CRP 2.2*
(MR # Printed by [113902] at 8/7/14 9:31 AM Page 3
History and Physical
H&P Notes (continued)
H&P by Brown, Laura D., M.D. at 3/22/2014 2:14 PM (continued)
UA
Recent Labs
03/22/14
1130
COLOR YELLOW
CHARACTER HAZY
BILIUA NEGATIVE
SP GREAT OR EQUAL 1.030
URODS 0.2
NITDS NEGATIVE
LEUDS NEGATIVE
WBCUA None Seen
RBCUR None Seen
AMORPHUR Small
BACTUR Small*
COMMENTUA Volume = 2 ML
CXR: RUL atelectasis, viral airways disease. ETT in slightly high position.
RVP: +for rhinovirus
Assessment: This is a ex 33 weeks gestation infant with hypothermia, apnea and emesis
of mucus, likely due to rhinovirus infection. She had hypotension in the ED, unclear if this was due to
dehydration given poor intake today, sedation administration for intubation, or sepsis, but has resolved since
admission to the NICU. She is on significant ventilator settings with CXR consistent with viral illness, but
remains paralyzed since her intubation, so cannot accurately gauge respiratory disease. Apnea likely due to
prematurity and rhinovirus, but cannot rule out meningitis or other serious bacterial infection as the cause.
Given age, HSV is also a concern, especially given report of severity of illness in ED and hypothermia on
admission. She is currently hemodynamically stable and well-hydrated appearing, paralyzed and intubated.
Plan:
FEN: NPO. Total fluids = 120ml/kg. Monitor for pulmonary edema given large amount of fluid boluses given.
Will start gavage feeds 20 kcal BM this afternoon, once paralysis wears off and bowel function improved.
Respiratory: Gas and chest xray on admission were reassuring. Will wean ventilator as paralysis wears off, as
tolerated. Consider tracheal aspirate if secretions are concerning.
CV: HDS. Monitor for hypotension.
ID: Blood and urine cultures sent from ED. CSF culture sent from NICU, although this culture is pretreated with
antibiotics by about 2 hours. Will try to assess cell count for risk of CNS infection. Will send CSF and serum
HSV PCR and will send HSV surface culture. Continue ampicillin and cefotaxime, but change to meningitic
dosing, and add acyclovir. Likely viral suppression of white blood cell count, will follow-up. Will consider
trending CRP to guide management.
Neurologic: Will assess neuro function as sedation and paralysis wears off. Fentanyl prn for sedation while
intubated.
Social: POC at bedside, updated on plan.
Discharge Plan:
Anticipate more than 72 hour hospitalization
Communication:
Patient seen and discussed with Dr. Brown.
(MR # Printed by [113902] at 8/7/14 9:31 AM Page 4
History and Physical
H&P Notes (continued)
H&P by Brown, Laura D., M.D. at 3/22/2014 2:14 PM (continued)
Satya (Sadie) Sekar, M.D.
Neonatology Fellow
Pager
Attending Note
Date of Service: 3/22/2014
Examined, monitored, and course reviewed multiple times during the day with NICU staff, fellow and NNP,
agree with findings and plans. I have seen the above patient with Satya Sekar, MD and agree with findings
and plans.
Laura D. Brown MD
1.Given health record shows the surfactant deficiency in newborn which causes the respiratory syndrome.
Apnea usually caused by structural and functional lung
immaturity in premature infants who born before 28-34 weeks(33 6/7
weeks).
It occurs 24000 infants in US annually.
Pathophysiology;
*immature type II alveolar cells produce less surfactant,causing
an increase in alveolar surface tension and a decrease in
compliance.
*resultanat atelectasis causes pulmonary vascular
constriction,hypoperfusion,and lung tissue ischemia.
*hyaline membranes form through the combination of sloughed
epitelium,protein and edema.
treatment:
the most effective strategy foraccelerating reabsorbtion of fetal
lung is exogenous glucocortcoids.
post natal cortocosteroid administration for respiratory distress
syndrome may decrease mortaliity risk,but may increase the risk of
cerebral palsy.
2.complaint query to physician;
Mother 20 years,gave birth to premature baby at 33 6/7 weeks
through normal vaginal labor with ropture of membranes
.and mother is G3,P1.prenatal health record showing no negative
records and reports.
The premature newborn developed apneic episodes without
desaturation and became worse in feeding and also intubated and
stabilised after the teatment for 48 hours.
the same apenic episodes have been observed at the time of the
birth and treated for 16 days from the day of delivery and
discharged on DOL17 (with low flow nasal cannula)when tolerated
full feeds and growing.
as the patient has been intubated other infections like meningitis
or bacterial infections also unable to rule out immediately at this
age of child.
on physical assessment showing no symptoms of HSV even.
the assessment of newborn weight: 2.3 kg,height:44.00cm,BP
64/32,temp 36.8,Resp 32,SpO299% on CMV 50%
already child paralysed ,and not having complete bowel function to
give feeds as per body weight.
respiratory function also controled by the ventilator and
secreations are removed if any excess through tracheal
aspiration.
prior antibiotics (ampicillin and cefotaxime)also started to treat
for any CNS infections.need to start acyclovir for meningitic
infections.
need to send HSV surface culture.
neurologic function to be assessed once ventilator wean off.
discharge plan is Anticipated more than 72 hours of hospilization
for stabilizing the condition.