tokens: Admission Date : 2015-11-09 Discharge Date : 2015-11-16 Date of Birth : 2015-11-09 Sex : F Service : CMED CCU HISTORY OF PRESENT ILLNESS : Baby girl Fritsche is the 1670 gram product of a 31 and 06-17 week gestation born to a 34 - year-old G2 P1 now 2 woman . Fetal screens , O positive , antibody negative , RPR nonreactive , rubella immune , hepatitis surface antigen negative , GBS unknown . IVF pregnancy complicated by IUGR , 2 vessel cord , normal fetal echo reverse diastolic flow and demise of twin A at 27 weeks . Twin B with normal fetal survey was transferred to Boston Medical Center at 26 and 2/7 weeks with IUGR of twin A was first noted , presented with preterm labor at 31 weeks . Betamethasone complete at approximately 26 weeks and 31 weeks . Mother was on clindamycin since 11-04 . PPROM with bleeding and transverse lie prompted cesarean section . Abruption noted . Apgars were 6 and 9 . PHYSICAL EXAMINATION : On admission weight 1670 grams approximately 50 th percentile , length 43 cm 50 th percentile , head circumference not done . Anterior fontanel soft , flat , cap and prong CPAP in place . Nondysmorphic intact Veliz . Comfortable with good aeration , clear breath sounds , does grunt intermittently when disturbed . No murmur . Normal pulses . Soft abdomen , 3 vessel cord . No hepatosplenomegaly . Normal female genitalia . Positive vaginal tag . Patent anus . No hip click . No sacral dimple . Moves all extremities . Decrease tone , ruddy , warm , well perfused with peripheral IV in left hand . HOSPITAL COURSE : Respiratory . Mills was admitted to the newborn intensive care unit with moderate respiratory distress . Infant placed on CPAP . X-ray revealed mild respiratory distress syndrome . She remained on CPAP for a total of 24 hours at which time she transitioned to room air and continues to be stable in room air . Caffeine citrate was initiated on 11-14 for apnea and bradycardia of prematurity . She is currently receiving 11 mg po every day . Cardiovascular . Has been cardiovascular stable throughout hospital course . Heart ranges 130 s to 160 s. Blood pressure most recently 60/37 with a mean of 44 . Fluid and electrolyte . Birth weight was 1670 grams 50 th percentile , length 43 cm 50 th percentile . Head circumference not done . Infant was initially started on 80 cc per kilo per day of D10W . Enteral feedings were initiated on day of life #1 . Infant achieved full enteral feedings by day of life 6 . She is currently receiving 150 cc per kilo per day of Special Care 20 . Her discharge weight is 1477 gm . Her most recent set of electrolytes were on 2015-11-13 with a sodium of 143 , a potassium of 6.3 hemolyzed , a chloride of 113 and a total CO2 of 17 . She will need advance calorie density for better growth . GI . Bilirubin peaked on day of life #2 of 9.0 / 0.3 . Infant is under phototherapy , which was discontinued on 11-13 . Most recent bilirubin was on 11-14 of 4.8 / 0.3 . Hematology . Hematocrit on admission was 53.7 . She has not required any blood transfusions . Infectious disease . A CBC and blood culture obtained on admission . CBC had a white blood cell count of 9 , 17 polys , 0 bands , platelets of 326 . She received 48 hours of ampicillin and gentamycin with negative blood cultures and antibiotics were discontinued . Neurological . She has been appropriate for gestational age . Head ultrasound was performed on 2015-11-16 and was normal . Sensory , hearing screen has not yet been performed , but should be done prior to discharge . CONDITION AT DISCHARGE : Stable . DISCHARGE DISPOSITION : To Boston Medical Center . PRIMARY PEDIATRICIAN : Dr. Kim Adams . Telephone number is ( 261 ) 564-6894 . CARE AND RECOMMENDATIONS : Continue 150 cc per kilo per day of Special Care 20 calories advancing caloric intake as required to maintain weight gain of 3 grams per kilogram per day . Medications , continue caffeine citrate of 11 mg po every day . Car seat position screening has not yet been done . State newborn screen was sent on day of life #3 and at discharge . Initial results were within normal limits . Immunizations received , infant has not received any immunizations to date . State newborn screen was sent on 2015-11-12 . Immunizations : recommended Synagis RSV prophylaxis should be considered from November through March for infants who meet any of the following 3 criteria , born at less than 32 weeks , born between 32 and 35 weeks with 2 of the following , daycare during RSV season , a smoker in the household , neuromuscular disease and weight abnormalities or school age siblings with chronic lung disease . Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age . Before this age and for the first 24 months of the child 's life immunizations against influenza is recommended for household contacts and out of home care givers . DISCHARGE DIAGNOSES : Premature infant born at 31 and 6/7 weeks gestation , resolved respiratory distress syndrome . Rule out sepsis with antibiotic . Hyperbilirubinemia resolving . Apnea and bradycardia of prematurity . Tai Pamela Wendell , Oklahoma 05158 Dictated By : Kurt S Imperato , M.D. MEDQUIST36 D : 2015-11-15 21:17:13 T : 2015-11-16 06:38:42 Job #: 82694 Signed electronically by : DR. Debbie TRAN on : MON 2015-11-16 9:57 AM ( End of Report )