tokens: Admission Date : 2017-09-22 Discharge Date : 2017-09-27 Date of Birth : 2017-09-22 Sex : M Service : CMED CSRU HISTORY : Peggy Hammock is a full term baby boy born at 38 1/7 weeks by repeat cesarean section to a 34 year old gravida III , now para II mother . Serologies include blood type O negative , antibody negative , RPR nonreactive . Hepatitis B surface antigen negative , rubella immune . Group B strep screening was negative . Pregnancy was uncomplicated until an occurrence of HSV outbreak occurred on 2017-09-13 approximately one week prior to delivery . Pregnancy was also complicated by maternal history of depression for which mother received Zoloft . On day of delivery mother presented in spontaneous labor . There were no sepsis risk factors . GBS negative . No maternal fever . Rupture of membranes at time of delivery . Delivery was by repeat cesarean section and Apgars of 8 and 9 were given at one and five minutes respectively . Baby appeared well and went to the newborn nursery and was breast feeding and undergoing routine newborn care . On the newborn nursery the mother called the nurse for concern of baby turning dusky while feeding . She called the nurses and patted the infant on the back . This episode was also accompanied by gagging motions noted of the infant . A second episode occurred where the baby turned pale . Mother thought the baby just did not look right . The baby did not turn blue at that time . The Neonatal Intensive Care Unit was notified and the baby was transferred to the Newborn Intensive Care Unit for further evaluation . PHYSICAL EXAMINATION : On admission to the Neonatal Intensive Care Unit : Full term well appearing infant with some facial jaundice , overall pink , warm and well perfused , alert and responsive . Anterior fontanelle is soft , open and flat . Ears are normally set . Red reflexes noted bilaterally . He had a left pupil that was in unequal in size with a keyhole appearance consistent with a coloboma . The nares were patent . Palate was intact . Mucous membranes were moist and pink . His neck was supple without masses or bruits . Lungs were clear to auscultation and equal . Comfortable respiratory pattern . Cardiovascular : Regular rate and rhythm , no murmur . 2 plus femoral pulses were noted . Abdomens oft with positive bowel sounds . Genitourinary : Infant was circumcised in the newborn nursery which was healing well . Testes were descended bilaterally . Extremities were pink and well perfused . Neurologic : Tone was appropriate for gestational age with equal strength , symmetric reflexes . HOSPITAL COURSE BY SYSTEMS : Respiratory : The infant was placed on a cardiopulmonary monitor upon admission to the Newborn Intensive Care Unit with pulse oximetry . He was noted to have an episode of desaturation related to feeding with desaturations in the 70 percent . This resolved spontaneously when the bottle was pulled from the baby 's mouth . Jule remained in room air without any evidence of respiratory distress and was without any further dusky spells or pale episodes in the 48 hours prior to discharge . Cardiovascular : Renee remained cardiovascularly stable with AP s noted to be 120 to 130 s. Blood pressure 84/43 with a mean of 59 . Fluid , electrolytes and nutritions : The baby had been breast feeding ad lib in the Newborn Nursery . He continued to feed ad lib while a patient in the Newborn Intensive Care Unit . He was fed with a bottle occasionally by his dad and had a vigorous suck and was noted to have some discoordination of his suck while breathing at the initial onset of feeding time . This resolved with removal of the bottle from the baby 's mouth . Breast feeding was limited to four to five minutes on each side per recommendation of neurology after their evaluation to try and minimize incidence of gastroesophageal reflux . Weight at time of discharge is 3.13 kilograms . Birth weight was 3.29 kilograms in the 75th percentile . Head circumference was 34.5 cm , 75th percentile , and length was 50.7 cm , also the 75th percentile . Gastrointestinal : Baby was noted to have frequent spitting episodes . This was minimized with limitation of volume at each feed with frequent feeding . He had normal voiding and stooling patterns . The baby demonstrated mild physiologic jaundice with a serum bilirubin obtained on day of life three which was 6.7 with a direct of 0.2 . Mother 's blood type is O negative . Infant 's blood type was O positive and Coombs was noted to be negative . Hematologic : In addition a complete blood count was obtained on admission with a white count of 10.1 with 43 polys and 0 bands . Hematocrit was noted to 47.5 with platelets of 257,000 . There were no blood products received during hospitalization . Infectious disease : A blood culture was obtained upon admission and Ampicillin and Gentamicin were given for 48 hours with blood cultures remaining sterile . Antibiotics were discontinued on day of life three and infant has remained clinically well off antibiotics . Neurology : Neurology was consulted due to the concern for seizures in the setting of dusky episodes . Neurology evaluated the baby and found the baby to have a normal neurological examination . An EEG was performed . The EEG showed transient sharp waves in the left front , left occipital and right parietal regions . There was no electrographic evidence of seizure activity noted . Sensory : Hearing screening was performed with automated auditory brain stem responses . Baby passed in both ears on 09-23 . Ophthalmology : Ophthalmology was consulted due to the presence of a coloboma into the left CMED . Ophthalmology noted that this left Martha coloboma was likely an isolated anomaly in the absence of other pathology . Follow up as below . Psychosocial : Cambridge Health Alliance social worker was involved with this family . She may be reached at ( 756 ) 599-4849 . CONDITION ON DISCHARGE : Good . DISCHARGE DISPOSITION : To home with parents . Primary pediatrician is Dr. Satterlund of Westborough Pediatrics . Telephone number is ( 739 ) 520-0347 . Fax number is ( 617 ) 455-4585 . Appointment is on Lyon , 10-30 . CARE AND RECOMMENDATIONS : Feeds are breast feeding P.O. ad lib . Medications are Tri-Vi-Michael 1 cc by mouth each day . Newborn state screen was sent on day of life three . Results are pending . Immunizations received are hepatitis B vaccine given on 09-26 . Follow up appointments scheduled : Neurology follow up with Dr. Workman is scheduled for 2017-10-20 at 12:30 pm at the Addison Gilbert Hospital of Oak Bluffs , Ison 11 . Phone number is 209-604-1402 . Follow up ophthalmology appointment is with Dr. Jundt on Ison 4 at the Addison Gilbert Hospital of Oak Bluffs in three months . Appointment to be scheduled by mom . Telephone number is 444 7700 . Boston Regional Medical Centerr Visiting Nurse Association has been asked to visit this family at home to follow up on feeding and parenting . DISCHARGE DIAGNOSES : Full term male infant with cyanosis episodes . Rule out sepsis . Left coloboma . Rule out seizures . Lucile Virgina , MD 50AAD Dictated By : Sherry G Christie , M.D. MEDQUIST36 D : 2017-09-27 17:51:44 T : 2017-09-27 18:26:21 Job #: 75510 Signed electronically by : DR. Marcus N Schartz on : Maxine 2017-09-28 9:34 AM ( End of Report )