Neonatal Hospital Note

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Patient Information:

• Name: Baby Elisa West

• MRN: 123456

• DOB: 10/01/2050

• Gestational Age: 32 weeks

• Birth Weight: 1500 grams

Date/Time: 10/08/2050 10:00 AM
Attending Physician: Dr. [Your Name]
Nurse: Nurse Jane

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Subjective:

The infant was admitted to the NICU for respiratory distress and hypoglycemia. The mother reports that the baby has been feeding poorly and exhibiting signs of increased work of breathing. No known drug allergies.

Objective:

Vital Signs:

• Heart Rate: 160 bpm

• Respiratory Rate: 70 breaths/min

• Temperature: 36.5°C

• Blood Pressure: 50/30 mmHg

Physical Examination:

• General: Alert, slightly lethargic.

• Respiratory: Tachypneic, bilateral retractions, grunting present.

• Cardiovascular: Heart sounds normal, no murmurs.

• Abdomen: Soft, non-distended, bowel sounds present.

• Extremities: Warm, pulses intact.

Laboratory Results:

• CBC: Hemoglobin 12 g/dL, WBC 10,000/µL, Platelets 150,000/µL

• Blood Glucose: 40 mg/dL (given D10W bolus)

• ABG: pH 7.35, pCO2 55 mmHg, pO2 60 mmHg

Assessment:

• Preterm infant (32 weeks) with respiratory distress likely secondary to immature lung development and possible hypoglycemia.

• Requires ongoing monitoring and supportive care.

Plan:

1. Continue oxygen therapy via nasal cannula.

2. Monitor vital signs every 2 hours.

3. Initiate enteral feeds with fortified breast milk, starting at 10 mL/kg/day.

4. Repeat blood glucose monitoring every 6 hours.

5. Consult neonatology for further evaluation of respiratory distress and potential CPAP initiation.

6. Parent education regarding signs of respiratory distress and feeding.

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Signature:

Dr. [Your Name], MD
Neonatologist

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