ADMITTING SERVICE:
DATE OF ADMISSION:
DATE OF TRANSFER:
ATTENDING PHYSICIAN:
Pediatric Intensive Care Unit
01/17/2009
02/05/2009
Saraswati Kache, MD
For a full record of this patient's admission history and physical, please see the
admission H&P dictated by myself on 01/17/2009, as well as the interim summary dictated
on 01/22/2009.
IDENTIFICATION: XXXXX is a 21-month-old male with a complex medical history, including
intractable epilepsy, spastic quadriplegic cerebral palsy, and profound mental
retardation, who initially presented with a 2-day history of respiratory distress and
fever, was found to be RSV positive and have a right middle lobe pneumonia. He was
initially transferred to the floor on 01/22/2009; however, over the course of the night,
was found to have increased respiratory distress and returned to the Pediatric Intensive
Care Unit. This summary will cover his hospital course from 01/23/2009 through
02/05/2009.
HOSPITAL COURSE BY SYSTEMS:
1. FLUIDS, ELECTROLYTES, AND NUTRITION/GASTROINTESTINAL: Given his respiratory
distress, XXXXX was made n.p.o. upon readmission to the PICU. He has required occasional
replacement of electrolytes. He was initially placed on IV fluids with the concern being
that he would need TPN given prolonged n.p.o. status. This was discussed with his
neurology team given that he is on a ketogenic diet, and it was thought that should he
need to go towards TPN, he would forego the ketogenic diet given that he would need
dextrose. We have not needed to provide XXXXX with any TPN during his hospital course
and, instead, have been able to advance him to his home feeds of his ketogenic diet. He
currently receives KetoCal formula 5 boluses per day of 90 mL each. He has been
tolerating his feeds well without any abdominal distention or problems with stool output.
Of note, he does have a history of constipation for which he normally receives milk of
magnesia at home. While he has been in the PICU, we have given him MiraLax to improve
his stool output.
2. CARDIOVASCULAR: XXXXX has had no problems with blood pressure instability throughout
his hospital course. He has had issues with tachycardia, initially secondary to mild
dehydration, as well as fevers; however, since being back in the PICU, he has had no
problems from a cardiovascular standpoint.
3. RESPIRATORY: Of note, XXXXX has a history of pneumomediastinum from his initial
trial on BiPAP when he was admitted to the Pediatric Intensive Care Unit. When he was
transferred back on 01/23/2009, he was on high-flow nasal cannula requiring approximately
10 liters per minute with an FIO2 of 80% to 100%. We have had pulmonary following him
during his time in our Pediatric Intensive Care Unit. He initially was requiring
continuous albuterol at 10 mg an hour. We have subsequently weaned him to albuterol q.6
h. In addition, he is currently on Atrovent q.6 h. Per pulmonology recommendations, we
have him on Pulmozyme at q.12 h., as well as Solu-Medrol. He will continue Solu-Medrol
taper through 02/09/2009, at which time it will be discontinued. In addition, he
initially was receiving Mucomyst inhaled, and we have subsequently switched that to a GPage 1 of 3
tube medication as a glutathione scavenger. With regards to his respiratory support, as
stated above, he was needing high-flow nasal cannula given for his desaturations,
especially related to coughing fits and bronchospasm. He was switched over to CPAP as
high as CPAP of 6. Given his history of pneumomediastinum with BiPAP, we tried our best
to wean him to a lower pressure on the CPAP and were able to get him down to a CPAP of 4.
He was switched over to high-flow nasal cannula again on 02/02/2009 and has tolerated
this well. He has subsequently been weaned to 2 liters nasal cannula with an FIO2 of 55%
and has had stable oxygen saturations. To note, during his hospital course, he has also
undergone an aminophylline infusion, which has since been discontinued. With regard to
his chest x-rays, he has had notable mediastinum in addition to the pneumothoraces noted
after institution of BiPAP. Upon return to the PICU, serial chest x-rays noted continued
mediastinum with worsening subcutaneous emphysema. His chest x-ray did show evidence of
what was thought to be right sinus; however, given his persistent issues with
oxygenation, XXXXX underwent a chest CT on 01/28/2009. The chest CT did note evidence of
a right-sided tension pneumothorax, in addition to pulmonary interstitial emphysema,
mediastinal and subcutaneous emphysema and pneumatocele, as well as ground-glass
opacities and consolidation in both lungs. Subsequent to this finding of tension
pneumothorax, XXXXX had a chest tube placed the evening of 01/28/2009.
It was initially
placed to 20 cm of water suction. On 02/01/2009, given his respiratory stability, his
chest tube was placed to water seal with no recurrence of pneumothorax on repeat chest xray.
His chest tube was discontinued on 02/04/2009 without any problems. Currently,
XXXXX is on 2 liters nasal cannula with FIO2 of approximately 50%.
4. NEUROLOGIC: As stated above, XXXXX has a history of intractable epilepsy previously
on antiepileptics. However, these have been weaned off and he is currently only on the
ketogenic diet. He did have questionable seizure activity around the 24th and 25th of
January. A neurological consult was obtained, and a 24-hour EEG was initiated. Per
neurology, he did not have any evidence of seizure activity on this EEG. Overnight on
01/25/2009, he also had concern for a left blown pupil. A stat head CT was performed,
which showed no evidence of herniation, ventriculomegaly, diffuse cortical atrophy which
was stable. XXXXX has had no further evidence of seizure activity while he has been in
the PICU.
5. HEMATOLOGIC: XXXXX has become somewhat anemic secondary to lab draws while in the
hospital. As such, we have put him on iron.
6. INFECTIOUS DISEASE: As stated above, XXXXX has been RSV positive on MP lab performed
on 01/17/2009, as well as 01/23/2009. Most recently, an MP lab performed on 01/22/2009
has returned negative. As such, he has been removed from contact precautions.
Initially, his chest x-ray showed evidence of right middle lobe pneumonia concerning for
possible aspiration. He has since completed a 7-day course of ceftriaxone and
clindamycin. Seconding to his coughing fits, there was concern for pertussis. A
pertussis lab test was performed and came back negative.
7. RENAL: Given his initial evidence of metabolic acidosis with a persistent base
deficit and low bicarbonate on chemistry panel, urine electrolytes were sent to evaluate
whether he was wasting bicarbonate in his urine. This returned as normal, and he has
since resolved his metabolic acidosis.
Page 2 of 3
8. SOCIAL: Both mother and father have been at the patient's bedside, and they have
been kept up to date and informed about the patient's hospital course.
PHYSICAL EXAMINATION:
GENERAL: In general, XXXXX is sleeping, in no apparent distress.
HEENT: He is microcephalic. He does have notable swelling at his forehead, as well as
his bilateral periorbital area, which is improved. Pupils are equal, round, and reactive
to light. There is evidence of breakdown of the skin at the bridge of the nose.
Oropharynx is clear.
NECK: Supple with no lymphadenopathy.
CARDIOVASCULAR: Regular rate and rhythm. No murmurs, rubs, or gallops.
LUNGS: Clear to auscultation, right greater than left, but much improved. No evidence
of wheeze. No evidence of retractions.
ABDOMEN: Soft, nontender, nondistended with positive bowel sounds. G-tube is clean, dry
and intact. There is no hepatosplenomegaly.
EXTREMITIES: Warm and well perfused. No clubbing, cyanosis or edema.
NEUROLOGICAL EXAMINATION: He does have truncal hypotonicity. He has increased deep
tendon reflexes. We did have him on a ketamine infusion secondary to his agitation, as
well as to help him from a pulmonary standpoint. He was up to as high as 20 mcg/kg per
minute, and he has subsequently been weaned off on 02/05/2009.
SKIN: XXXXX does have crepitus palpated at his face, chin, neck, upper chest and
abdomen, as well as his upper extremities; however, this is much improved over the last
48 hours.
MEDICATIONS:
1. Tylenol 85 mg per rectum q.4 h. p.r.n. discomfort, fever.
2. Acetylcysteine 255 mg per G-tube q.8 h.
3. Albuterol 5 mg inhaled q.6 h.
4. Albuterol 2.5 mg inhaled q.2 h. p.r.n.
5. Benadryl 5 mg IV q.6 h. p.r.n. agitation.
6. Pulmozyme 2.5 mg inhaled q.12 h.
7. Ferrous sulfate 40 mg per G-tube 2 times daily.
8. Glycerin suppositories 1 suppository rectal p.r.n. constipation.
9. Atrovent 0.25 mg inhaled q.6 h.
10. Milk of magnesia 5 mL per G-tube daily.
11. Versed 0.5 mg IV q.2 h. p.r.n. agitation.
12. Morphine 0.5 mg IV q.2 h. p.r.n.
13. Protonix 10 mg IV q.12 h.
14. MiraLax 4.25 mg per G-tube daily p.r.n. constipation.
15. Solu-Medrol taper.
Page 3 of 3