1. Describe at least one deficiency that was present in the health record and wo

Q: 1. Describe at least one deficiency that was present in the health record and wo

Hypothermia Symptoms of hypothermia include:

ID: 241345 • Letter: 1

Question

1. Describe at least one deficiency that was present in the health record and would require a physician query to resolve:

2. Compose a query to physician to resolve deficiency:

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

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)

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

Explanation / Answer

Hypothermia

Symptoms of hypothermia include:

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