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History & Physical Write-Up – Intrauterine Growth Restriction

H&P2 – NICU – Prader-Willi

IDENTIFICATION: April 3, 2019, 7:00AM.

JE, F, White, American, 41 days old, single, 567 234th Street, Queens, NY 13127, Muslim.

INFORMANT: NICU nurses are reliable historians.

REFERRAL SOURCE: Dr. S. Pinchi

CHIEF COMPLAINT: Intrauterine Growth Restriction/Poor Feeding

PRESENT ILLNESS: JE is a 42 day old female, with a PMH of IUGR, followed in the NICU today for poor oral feeding and weight gain.  Patient was born 34 1/7 weeks, with an adjusted gestational age of 40 1/7 weeks, on day 43 of life today. Patient in stable condition and working on nippling with improvement over the past week but growth and oral intake is still slow.

Patient received Hep B vaccination in the newborn nursery.  Patient passed newborn hearing and congenital heart disease screening in NICU.  

Prenatal history within normal limits, all serologies negative, including GBS.

Birth Weight: 1480g

Today’s Weight: 2475 (Up 25g from previous day)

Maternal Blood Type: A+

Newborn Blood Type: N/A

Postnatal course remarkable for poor feeding, no jaundice. Patient sleeping in open crib on back.  Voiding and stooling adequately. Mother not present in the NICU.

PAST MEDICAL HISTORY

  • Intrauterine Growth Restriction

PAST SURGICAL HISTORY

  • N/A

MEDICATIONS

  • Tri-Vi-Sol, 1mL PO q24h
  • Ferrous Sulfate Peds Drops, 75mg/mL (15mg/mL), 8.8 mg PO qd

ALLERGIES

  • NKDA
  • No known food/environmental allergies

FAMILY HISTORY

  • Mother, 28 – no current medical problems or disability
  • Father, 34 – DM
  • Brother, 3 – no current medical problems, was born at 39 weeks, normal size for gestational age.
  • Maternal Grandfather – HTN, hyperlipidemia
  • Paternal Grandfather – DM, HTN
  • Maternal Grandmother – HTN
  • Paternal Grandmother, deceased – breast cancer

SOCIAL HISTORY

  • Day 43 in NYPQ NICU
  • Both parents non-smokers, deny EtOH and illicit drug use

REVIEW OF SYSTEMS
General: NICU nurses report poor feeding / nippling.  
Skin, hair and nails:  NICU nurses deny rashes, adenopathy, lumps, bruising and bleeding, pigmentation changes.
HEENT: NICU nurses deny any unusual head shape, strabismus, conjunctivitis, visual problems, hearing, ear infections, draining ears, colds, mouth breathing, snoring, apnea, oral thrush, epistaxis.
Pulmonary System: NICU nurses deny bronchiolitis, wheezing, chronic cough, sputum, coughing up blood, history of TB.
Cardiovascular System:  NICU nurses deny any shortness of breath and bluish discoloration, history of heart murmurs.
Gastrointestinal System: NICU nurses report yellow/green stool with seed like appearance. Report two episodes of emesis post feeding overnight.   Deny diarrhea, constipation, vomiting blood, jaundice or colic.
Genitourinary System: NICU nurses deny frequency, discharge, blood in urine or facial swelling.
Musculoskeletal:  NICU nurses deny fevers, weakness, injuries, swelling or trauma.
Nervous System: NICU nurses deny seizures or loss of consciousness.
Hematologic System:  NICU nurses deny bruising or bleeding.

GENERAL SURVEY:  43 day old female alert and active.  Patient appears small for gestational age.  Normal tone and color. Patient is in no acute distress.

VITALS

BP: 67/27 mmHg

R: 67 breaths per minute

P: 146 beats per minute

SpO2: 98% on RA

Temperature: 36.7 C (axillary)

Height: 19.1 in (lying)                         Weight: 5lbs 45 oz (without clothes)                     BMI: 10.5

PHYSICAL EXAM

SKIN: Pink.  Warm & dry, good turgor.  Nonicteric, no lesions or rashes noted.

HAIR: Small quantity & equal distribution.

NAILS: Capillary refill <2 seconds throughout.

HEAD: Normocephalic.  No cephalohematoma.  AF flat, sutures open with no clefts.  

EYES: Red Reflex present bilaterally.  No conjunctival injection bilaterally.

EARS: Symmetrical & normal size.  Ear canals patent AU. No evidence of lesions, masses, trauma on external ears.

NOSE: Symmetrical, no obvious masses, lesions, deformities, trauma, discharge.  Nares patent bilaterally & well hydrated.

LIPS: Pink, moist, no evidence of cyanosis or lesions.

MUCOSA: Pink, well hydrated. No masses; lesions noted.

PALATE: Pink, well hydrated. No cleft palate.  Intact with no masses, lesions or scars.

GINGIVAE: Pink, moist.  No evidence of hyperplasia, masses, lesions, erythema or discharge.

TONGUE: Within normal limits.  Pink, well hydrated.

NECK: Trachea midline, no masses, lesions, scars noted. Clavicles intact.  

CHEST/LUNGS: Symmetrical, no deformities, no evidence of trauma.   Clear breath sounds and good aeration bilaterally. No wheezing, rhonci, crackle, rales noted.

HEART:  Normal precordial activity.  No murmurs noted. Femoral pulses noted bilaterally.

ABDOMEN: Soft, non-tender.  Normal bowel sounds.  No masses or significant discoloration.  Umbilical hernia, small & easily reducible.  No significant organomegaly.

BACK: Symmetrical.  Spine palpable along length.  No sacral dimple, no hair tuft. No masses, lesions or tags noted.

GENITALIA: Normal female genitalia for newborn, patent urethra and vagina.  Anus patent.

EXTREMITIES:  Hips stable bilaterally.  No gross deformities.

NEURO: Normal tone with symmetrical spontaneous movement.  Normal suck, grasp and moro reflexes.

DIAGNOSTICS:

  • LABS
      1. WBC: 7.73
      2. Hgb: 8.8
      3. Hct: 28.4%
      4. MCV: 89.9
      5. PLT: 352
    2. DNA Methylation: drawn (4/2), awaiting results for Prader-Willi.
  • IMAGING
      1. Head US: no signs of intraventricular hemorrhage or other abnormalities
  • FEEDINGS
    1. 24 Calorie/Ounce Special Care @ 48mL q3h with PO feeds twice a shift
    2. Total Fluids: 155 mL/kg/day
    3. Total Caloric Intake: 140 cal/kg/day

ASSESSMENT: 43 day old female, with IUGR, followed in the NICU for poor oral feeding and poor growth.  DNA methylation labs sent to evaluate for Prader-Willi Syndrome, awaiting results.

PLAN:

  • Poor Oral Feeding / Insufficient Weight Growth
    1. Continue to work on feeding/nippling in NICU
      1. Increase to 27 calorie/ounce special care formula with goal of PO intake of 48mL q3h
    2. Follow DNA Methylation results for evaluation of Prader-Willi Syndrome
    3. Speech consult requested and obtained
      1. Speech therapy initiated for PO feeds in NICU to work on nippling
    4. Neuro consult requested and obtained
      1. Order MRI to evaluate for any brain stem abnormalities

DDx:

  1. Prader-Willi Syndrome
  2. Poor sucking and coordination
  3. Failure to thrive
  4. Hypothyroidism
  5. Neonatal Brainstem Dysfunction

 

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