tokens: Admission Date : 2015-06-05 Discharge Date : 2015-06-10 Date of Birth : 2015-06-05 Sex : M Service : Neonatology HISTORY : The patient is a 1,770 gram male infant born by stat cesarean section for fetal bradycardia at 30-6/7 weeks gestation to a 29-year-old gravida 3 , para 0 now 1 mother . The pregnancy was unremarkable until 2015-06-01 when the mother presented to Shriner 's Hospital for Crippled Children for increased blood pressure and proteinuria . She was transferred to Charles River Hospital and was treated with magnesium sulfate and betamethasone . The morning of admission the mother developed vaginal bleeding and fetal bradycardia was noted . Therefore , a stat cesarean section was performed . The infant emerged limp and without spontaneous respiratory effort . He was given bag mask ventilation with good response . Apgar scores were 6 at one minute and 8 at five minutes . PRENATAL SCREENS : O+ , hepatitis B surface antigen negative , RPR nonreactive , rubella immune . ADMISSION PHYSICAL EXAMINATION : The birth weight was 1,770 grams . The patient was in mild to moderate respiratory distress . He was a nondysmorphic male . Anterior fontanel was soft , open and flat . The ears and eyes were normally placed . The palate was intact . The oropharynx was benign . Neck was supple without masses or defects . The lungs were coarse bilaterally with moderate retractions . The cardiovascular examination revealed S1 and S2 regular , no murmurs , 2+ femoral pulses . He was warm and well perfused . The abdomen was benign , flat , nontender , nondistended , no hepatosplenomegaly . He had a normal male phallus and bilaterally descended testes . The anus was patent and normally placed . Hips were stable without clunk . The extremities were normal in appearance . The skin was without lesions . The neurological examination was appropriate for age with normal tone and strength and appropriate reflexes . HOSPITAL COURSE : 1. Cardiovascular : The patient remained cardiovascularly stable throughout the admission . He was noted to have some apnea and bradycardic spells of prematurity and was therefore started on caffeine . With the initiation of caffeine therapy the patient has had no more apnea or bradycardic events . 2. Respiratory : The patient was initially started on nasal prong CPAP at 6 and required additional oxygen to 35% . However by 24 hours he transitioned to low-flow nasal cannula and on day of life five transitioned to room air where he currently remains . 3. Fluids , electrolytes and nutrition : The patient was initially maintained on intravenous fluids only and when his respiratory distress resolved he was transitioned to enteral feeds . The morning of transfer his IV came out so he has just been advanced to 120 cc per kg per day of PE-20 and his tolerating these PG feedings without difficulty . Last set of electrolytes on 06-08 , DOL3 : Na 145 , K 4.3 , Cl 110 , tCO2 25 . Discharge Wt 1645 gms . 4. Hematology : His admission complete blood count was notable for a white count of 11.8 , 25 polys and no bands . Hematocrit was 45 , platelet count 270 . He developed physiologic hyperbilirubinemia ( peak bili 8.6/0.3 on 06-08 , DOL3 ) for which he was treated with a single phototherapy . His most recent bilirubin was 6.6 on day of life six , the day of discharge , and his phototherapy was discontinued. He will need a rebound bilirubin level in am . 5. Infectious disease : Blood culture was sent but he was never started on antibiotics . The blood culture remained sterile . He was noted to have an erythematous perianal rash and for this was started on Nystatin powder . The parents were updated throughout the admission and a family meeting was held on 2015-06-09 . 6. Sensory : The patient has not had an CMED examination or hearing test . CONDITION ON DISCHARGE : Good . DISPOSITION : To Kindred Hospital Special Care Nursery . NAME OF PEDIATRICIAN : Hale Air Force Base Pediatrics . CARE AND RECOMMENDATIONS : Feeds at discharge are PE-20 currently at 120 cc per kg per day due to advance 15 cc per kg per day to a total of 150 cc per kg per day . DISCHARGE MEDICATIONS : Caffeine 12 mg pg q day. He has not had his 06-10 dose . STATE NEWBORN SCREENING STATUS : He is due to have his state screen sent today . IMMUNIZATIONS : Not yet received . Synagis RSV prophylaxis should be considered from October through April for infants who meet any of the following criteria : 1. Born at less than 32 weeks . 2. Born at 32-35 weeks with plans for day care during RSV season with a smoker in the household , or with preschool age siblings . 3. With chronic lung disease . Influenza vaccination 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 . DISCHARGE DIAGNOSES : 1. Prematurity at 30-6/7 weeks . 2. Rule out sepsis , off antibiotics . 3. Apnea and bradycardia of prematurity . 4. Hyperbilirubinemia . 5. Feeding immaturity . Freddy Stephen , M.D. 55-454 Dictated By:Nathan D. Delgadillo , M.D. MEDQUIST36 D : 2015-06-10 09:35 T : 2015-06-10 09:51 JOB# : 53951 Signed electronically by : DR. Freddy King on : WED 2015-06-10 11:54 AM ( End of Report )