HISTORY OF PRESENT ILLNESS: This baby boy was delivered by C-section to a (XX)-year-old gravida 1, para 0 mother at 33 and 2/7 weeks' gestation. Prenatal history was significant for placenta previa with active bleeding that led to the C-section. Apgar scores were 7 at one minute, 8 at five minutes. At the time of delivery, the infant received blow-by oxygen, suctioning, stimulation.
PHYSICAL FINDINGS ON ADMISSION: Twin B male AGA newborn infant. Birth weight 2060 grams. Birth length 46 cm. Head circumference 32 cm. Vital Signs: Temperature 98.4. Heart rate 160. Respiratory rate 36. Blood pressure 54/36. Admission Chemstrip of 33. On room air, pulse oximetry greater than 90%. Skin: Good capillary refill. No rashes and no bruises. HEENT: Anterior fontanelle open and flat. Eye exam deferred. Palate intact. Lungs: Good air entry bilaterally. Cardiovascular: Regular rate and rhythm, no murmur. Abdomen: Soft, no masses. Extremities: Moving all. Hips stable. Genitalia: Grossly normal male, testes palpable. Neurologic: Fair tone. Anus: Patent.
FEEDINGS: Ad lib NeoSure.
IMPRESSION ON ADMISSION:
1. Premature appropriate for gestational age male newborn infant.
2. Twin B.
3. Observed for sepsis.
INITIAL TREATMENT: NICU admission, CBC and blood culture. NPO and IV fluids for hypoglycemia protocol.
1. Hypoglycemia: The infant had admission Chemstrip of 33 mg/dL, responded very well to the initiation of intravenous fluid with D10 water.
2. Infectious: Antibiotics were given. CBC was benign. Blood culture was negative.
3. Thrombocytopenia: Admission platelet count was 87,000 and subsequent CBC revealed the platelet count to be 102,000. CBC done prior to discharge and those results are pending.
4. Nutrition: The infant required IV fluids for first 3 days of life. Enteral feeding was begun on day 1 of life, was full enteral feeding by day 3-4 or 5. The infant did require partial gavage feedings until day 14 of life. Presently, the infant is tolerating NeoSure ad lib on demand very well.
DISCHARGE PHYSICAL EXAMINATION: Weight on discharge 2146 grams, length 46.5 cm and head circumference 33 cm. The baby is an active, alert, well appearing preterm male newborn infant. HEENT: Eyes: Positive red reflex, both eyes. Neck: Supple. Lungs: Clear breath sounds. Heart: Regular rate and rhythm, no murmur. Abdomen: Soft and positive bowel sounds. Genitalia: Uncircumcised penis, descended testes. Extremities: Moving all limbs. Hips are stable. Skin: Negative rash. Neurologic: Good head control. Positive Moro, positive grasp reflexes.
1. Hearing screen was within normal limits.
2. Hematocrit was 52% on MM/DD/YYYY.
3. Metabolic screenings were done on MM/DD/YYYY and MM/DD/YYYY, both results are pending.
DISCHARGE FOLLOWUP: With Dr. Doe in 3-4 days.
1. Preterm twin B appropriate for gestational age male newborn infant.
2. Observed for sepsis.
3. Mild thrombocytopenia.
4. Mild hypoglycemia.
Pediatric Discharge Summary Samples #1 Discharge Summary Sample Reports #2