| Perry, Bailey G. |
| MRN: 421103 | Room: 852 | DOB: 8/17/2025 | Age: 0.002 | Gender: Female | Allergies: No known drug allergies |
| Setting | Neonatal Intensive Care Unit (NICU) | ||||||||||||
| Scenario | Bailey G. Perry is admitted to your NICU. The medical team thinks the respiratory decompensation is from HSV infection that needs to be immediately addressed to prevent further clinical decompensation. The attending asks you to work with the intern to get medications ordered regarding acute care of Bailey G. Perry as well as any other pertinent pharmacologic management needed based on her past medical history and labs. | ||||||||||||
| Admission note taken on 10/19/25 | |||||||||||||
| CC | “Congenital infection” | ||||||||||||
| HPI | Bailey G. Perry is an estimated 37w3d neonate born to Leslie Parks who presented to the ED in labor. Spontaneous rupture of membranes occurred in the ED and mother was transferred to the labor and delivery unit where she delivered precipitously. The neonate was admitted to the level I nursery for observation and withdrawal monitoring. The neonate voided shortly after delivery and a urine drug screen was sent secondary to absence of prenatal care. At 4 hours after birth the neonate developed grunting with nasal flaring and was placed on noninvasive positive pressure with an FiO2 requirement of 21%. The patient was also noted to have clear vesicles on the left leg at this time. Given the change in clinical status a chest x-ray, blood gas, complete blood cell count, blood cultures, viral cultures, and other labs were obtained. The patient was also made NPO. While attempting to place a peripheral intravenous line, the neonate had a brief episode of desaturation with a dusky appearance requiring 100% FiO2 to recover. She was subsequently weaned to 30% oxygen over the next 30 minutes. The neonatal team was called for transport of the patient to the level IV NICU for further management. Upon arrival to the NICU, the medical team places an umbilical venous catheter (UVC) for access and performs a lumbar puncture. At the time her weight was 3 kg (21st percentile), height was 48 cm (30th percentile), and head circumference was 34 cm (33rd percentile). |
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| PMH |
Narrative
Neonatal Delivery Room Course
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| Social History |
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Family History |
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| Vaccine History |
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Surgical History |
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| Physical Exam |
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| Test Name | 10/19/25 | Range |
| Sodium (Na+) | 135 | 136-145 mEq/L |
| Potassium (K+) | 4.7 | 3.5-5 mEq/L |
| Chloride (Cl-) | 102 | 98-106 mEq/L |
| Bicarbonate (HCO3-) | 22 | 23-28 mEq/L |
| Urea nitrogen (BUN) | 10 | 8-20 mg/dL |
| Creatinine | 0.6 | 0.5-1.3 mg/dL |
| Glucose | 80 | 70-115 mg/dL |
| Hemoglobin A1c | 5.3-7.5 % | |
| Calcium,Total | 9.4 | 8.6-10.2 mg/dL |
| Phosphate | 5 | 3-4.5 mg/dL |
| Magnesium | 2.1 | 1.6-2.6 mEq/L |
| Protein, total | 5.5-9 g/dL | |
| Albumin | 3.3 | 3.5-5.5 g/dL |
| Aminotransferase,aspartate (AST) | 938 | 10-40 units/L |
| Aminotransferase,alanine (ALT) | 1,257 | 10-40 units/L |
| Lactic dehydrogenase (LDH) | 80-225 units/L | |
| Alkaline phosphatase | 30-120 units/L | |
| Bilirubin, Total | 6.1 | 0.3-1 mg/dL |
| Leukocytes (WBC) | 15.4 | 4.5-11 x103/mcL |
| Red blood cells (RBC), Female | 4.3-5.7 x108/mcL | |
| Hemoglobin, Female | 12.5 | 12-16 g/dL |
| Hematocrit, Female | 36.9 | 37-47 % |
| Mean corpuscular hemoglobin (MCH) | 27-33 picogram | |
| Mean corpuscular volume (MCV) | 76-100 mcm3 | |
| Platelets | 72 | 150-450 x103/mcL |
| International normalized ratio (INR) | 0.8-1.2 | |
| Prothrombin time (PT) | 9.5-11.3 sec | |
| Partial thromboplastin time,activated (aPTT) | 25-35 sec |
| Additional Labs: |
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| Cultures: |
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| Imaging Studies: |
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| Medication History |
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| Patient Name: Perry, Bailey G. Date of Birth: 8/17/2025 Room#: 852 |
Allergies: |
Immunization History: |
| Community Rx Info: Rx Insurance: |
Social History: |
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| Additional Notes: | ||
STRENGTH DF |
ROUTE FREQ |
DOSE (date/time) |
EFFECTS |
ACTION |
REASON |
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|---|---|---|---|---|---|---|---|---|
| Action Key: C = Continue, D = Discontinue*, H = Hold*, M = Modify* *must provide reason |
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| Medication | 10/19/25 |
| Dextrose 10% IV continuous Rate: 10 mL/hr | 8:16 |
| Erythromycin 0.5% ophthalmic ointment OU x1 dose | 8:45 |
| Phytonadione 1 mg IM x1 dose | 8:28 |
| Hepatitis B vaccine 10 mcg/0.5 mL IM x1 dose | 8:27 |
| Hospital Medications | ||||||
| Medication | Instructions | Comments | Continue | Modify | Discontinue | New Rx sent |
| Previous Home Medications | ||||||
| Medication | Instructions | Comments | Continue | Modify | Discontinue | New Rx sent |
| Patient Name: | ||
| Admission Date: | Discharge Date: | Service: |
| Principle Diagnosis on Admission: | ||
| Secondary Diagnosis: | ||
| Allergies: | ||
| Medications ADDED this visit: (begin taking these) |
Medications CHANGED this visit: (modify what you were taking) |
Medications STOPPED this visit: (stop taking these) |
| Final Discharge Medication List | |||||
| Medication/Route/Dosage/Frequency/Duration | Comments | Morning | Afternoon | Evening | Bedtime |
| As Needed Medications | |||||
| Patient Name: Perry, Bailey G. | Date of Birth: 8/17/2025 | Room: 852 |
| Medication (name/strength) | Dose | Route | Frequency | Notes |