Blake Photo Time-Line

BRMH NEONATAL INTENSIVE CARE 17000 Medical Center Dr Baton Rouge LA 70816

Grondin, Blake John MRN: 12051461, DOB: 2/14/2020, Sex: M Acct #: 72010142213 Adm: 2/14/2020 02/14/2020 - Admission (Discharged) in O'Neal - NICU (continued)

Discharge Summary Note (continued) Respiratory: respiratory effort (normal); breath sounds (bilateral, clear); Cardiac: precordium (normal); rhythm (sinus rhythm); murmur (no); perfusion (normal); pulses (normal); Abdomen: abdomen (soft, nontender, flat, bowel sounds present, organomegaly absent); Genitourinary: genitalia (normal, term, male) circumcised; testes (bilateral, descended); Anus and Rectum: anus (patent); Spine: spine appearance (normal); Extremity: deformity (no); range of motion (normal); Skin: skin appearance (term); Neuro: mental status (responsive); muscle tone (hypertonic); intermittent jitteriness (mild) in extremities observed; Moro reflex hyperactive; DIAGNOSES (RESOLVED) 1. Newborn (suspected to be) affected by other maternal conditions (P00.89) Onset: 2/15/2020 Resolved: 2/15/2020 Comments: Eye prophylaxis given at birth. 3. Neonatal jaundice, unspecified (P59.9) Onset: 2/15/2020 Resolved: 2/19/2020 Comments: Newborn screening 3.9 at 36 hours. Level was well below threshold. 4. Slow feeding of newborn (P92.2) Onset: 2/16/2020 Resolved: 2/20/2020 Comments: Gavaged overnight for tachypnea. Nippling improved with resolution of tachypnea. Last gavage feed 2/16 @ 0500. Completing all nipple attemps, more than adequate volume. 5. Other specified disturbances of temperature regulation of newborn (P81.8) Onset: 2/15/2020 Resolved: 2/23/2020 Comments: Admitted to crib. Infant required rewarming x 1 overnight 2/17. Remains in open crib. 6. Encounter for examination of ears and hearing without abnormal findings (Z01.10) Onset: 2/15/2020 Resolved: 2/23/2020 Procedures: - Newborn Hearing Screen on 2/15/2020 Generated on 7/19/22 2:38 PM 2. Hemorrhagic disease of newborn (P53) Onset: 2/15/2020 Resolved: 2/15/2020 Comments: Vitamin K prophylaxis given at birth.

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