tokens: Admission Date : 2008-12-24 Discharge Date : 2009-02-06 Date of Birth : 2008-12-24 Sex : F Service : Neonatology HISTORY OF PRESENT ILLNESS : Gerardo is the 1400 gm product of a 32 05-03 week twin gestation born to a 37 year old gravida 1 , para 0 mother . Prenatal laboratory values : Maternal blood type 0-positive , DAT negative , negative , RPR nonreactive . The mother 's past medical history is significant for : 1. Tuberculosis , mother was treated in 2001 according to chart with subsequent negative chest x-ray , and 2. Infertility . The pregnancy was complicated by twin gestation and by polyhydramnios with apparent duodenal atresia and nuchal thickening consistent with Trisomy 21 in the B co-twin . Amniocentesis was not performed . Maternal hypertension was noted in the doctor 's office and Mom was referred to nonreassuring fetal tracing , necessitating an urgent cesarean section . Twin #1 cried spontaneously at birth , was bulb suctioned and received Blow-by oxygen . Apgars were 8 at one minute and 8 at five minutes . Twin #1 was noted to be in a breech presentation . Sepsis risk factors : No fever , no fetal tachycardia , rupture of membranes at delivery . Group B Streptococcus status unknown . PHYSICAL EXAMINATION : Well-appearing female without distress on admission to the Newborn Intensive Care Unit . The patient had a weight of 1400 gm , length 41.5 cm and head circumference of 29.25 cm . Anterior fontanelle , soft and flat , palate intact , nondysmorphic features . Lungs : breath sounds clear and equal bilaterally , no retractions . Heart : regular rate and rhythm , no murmur , normal S1 and S2 , pulses 2 +. Abdomen : soft , nondistended . Without hepatosplenomegaly , without masses . Normal female genitalia . Anus patent . Positive suck , positive grasp . Skin intact . Size appropriate for gestational age , 32 week female . SUMMARY OF HOSPITAL COURSE : 1. Respiratory - Gerardo was initially placed in nasal cannula oxygen to maintain oxygen saturation greater than 94 . On day of life #1 , caffeine was started . Gerardo weaned to room air on day of life #6 . Caffeine was discontinued on day of life #19 . Breath sounds , clear and equal , without retractions , respiratory rate 30 s to 60 s. 2. Cardiovascular - The patient has been cardiovascularly stable without murmur . 3. Fluids , electrolytes and nutrition - Birthweight was 1400 gm , 25th percentile . The patient was initially started on D10 / W at 80 cc / kg / day . She began enteral feeds on day of life #2 advancing to mother 's breastmilk 30 with ProMod at 150 cc / kg / day . Baby received parenteral nutrition and lipids for four days . No hypoglycemia issues noted . Baby is presently tolerating mother 's breastmilk with Enfamil powder to make 24 cal / oz at 130 cc / kg / day . The baby is breastfeeding well . The plan is for alternating feeds . 4. Gastrointestinal , genitourinary - Peak bilirubin 8.5 , phototherapy times 24 hours . Rebound bilirubin 6.4 . 5. Hematology - Most recent hematocrit was 42.8 on 50-05-25 . The baby received no blood products . 6. Infectious disease - No sepsis risk factors . Initial complete blood count with white blood cell count 14 , hemoglobin 21.6 , hematocrit 62.9 , 65 neutrophils , no bands , 28 lymphocytes . Blood cultures negative . 7. Neurology - Normal head ultrasound on 2009-01-08 . 8. Sensory - Audiology , hearing screening was performed with automated auditory brain stem responses . Baby passed hearing test on 2009-01-21 . Follow up recommended in eight months . Ophthalmology : eyes were examined most recently on 2009-01-14 , revealing mature retinal vessels . A follow up examination is recommended in six to eight months . 9. Psychosocial - Bridgewater State Hospital Center 's social work involved with family . The contact social worker is Barbara Cole and she can be reached at ( 972 ) 433-8086 . CONDITION ON DISCHARGE : Stable . DISCHARGE DISPOSITION : Home . PRIMARY PEDIATRICIAN : Dr. Vito Dotzler , phone ( 259 ) 579-8396 , fax 898-3942 . RECOMMENDATIONS : 1. Feeds - Breastfeeding ad lib , supplementing with Enfamil 24 or breastmilk 24 cal / oz made with 1 tsp of Enfamil powder per 100 cc of breastmilk . 2. Medications - Poly-Vi-James 1 cc p.o. q. day ; Iron or Fer-In-James 0.2 cc p.o. q. day to give 2 mg / kg / day 3. Car seat screening - Passed . 4. State newborn screening - Last on 2009-01-07 , all within normal range . 5. Immunizations received - Hepatitis B vaccine given 2009-01-22 . 6. Immunizations recommended - Synagis respiratory syncytial virus prophylaxis should be considered from October through April for infants who meet any of the following three criteria - 1. Born at less than 32 weeks ; 2. Born between 32 and 35 weeks with plans for daycare during respiratory syncytial virus season , with a smoker in the household or with preschool siblings ; or 3. With chronic lung disease . After some debate , we concluded that Vetrano was not at unusually high risk from RSV , but that her sister might be . Vetrano probably does not need Synagis at least until her sibling is discharged from the hospital . It may then be reasonable to treat both for the balance of the RSV season . Influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age , before this age the family and other caregivers should be considered for immunization against influenza to protect the infant . 7. Follow up - Follow up appointment with primary pediatrician within five days of discharge . DISCHARGE DIAGNOSIS : 1. Prematurity , former 32 4/7 weeks , Twin #1 2. Rule out sepsis Beverly Q. Bailey , M.D. 02-131 Dictated By : Carmen Y.R. Martinez , M.D. MEDQUIST36 D : 2009-02-05 18:20 T : 2009-02-05 18:39 JOB #: 17371 Signed electronically by : DR. Lizzie Calkins on : Adeline 2009-02-06 10:27 AM ( End of Report )