Medical Text: Admission Date:  [**2191-7-13**]       Discharge Date:  [**2191-7-15**]

Date of Birth:   [**2191-7-13**]       Sex:  M

Service:  NEONATOLOGY
HISTORY:  Baby [**Name (NI) **] [**Known lastname 1661**] was born at 39 weeks gestation to
a 32-year-old gravida 1, para 0 now 1 woman.  The mother's
prenatal screens were blood type O positive, antibody
negative, rubella immune, RPR nonreactive, hepatitis surface
antigen negative, and group B strep negative.  The infant
not crying and was intubated and no meconium was suctioned
from below the cords.  He was given a brief period of bag and
mask ventilation with good responses.  Apgars were 8 at two
minutes and 9 at five minutes.

His birth weight was 3885 grams, his birth length was 20 [**1-19**]
inches, and his birth head circumference was 34 cm.  The
transferred to the Newborn Intensive Care Unit at four hours
of age for hypoglycemia.  His blood dextrose stick was 36.

PHYSICAL EXAMINATION:  Reveals a vigorous, non-dysmorphic,
term-appearing infant.  Anterior fontanel open and flat,
cranial molding present, small caput posteriorly, palate
intact.  Respirations unlabored, lung sounds clear and equal.
Heart was normal heart sounds and no murmur.  Femoral and
brachial pulses +2 and equal.  Soft abdomen with no masses.
Normal external male genitalia with both testes descended.
Symmetric tone and reflexes.

HOSPITAL COURSE BY SYSTEM:
1.  Respiratory:  The infant has remained in room air
throughout his Newborn Intensive Care Unit stay.  He has had
no apnea, bradycardia or desaturations.

2.  Cardiovascular:  He has remained normotensive throughout
his Newborn Intensive Care Unit stay.  There are no
cardiovascular issues.

3.  Fluids, electrolytes and nutrition:  The infant required
supplemental intravenous fluid, from which he weaned
successfully at 28 hours of age, maintaining euglycemia with
feedings of Enfamil 20 on an ad lib schedule, taking
approximately one ounce every three to four hours.  His last
blood glucose at the four hour mark was 59.

4.  Gastrointestinal:  The infant has been passing meconium.

5.  Sensory:  Hearing screening was performed with automated
auditory brain stem responses, and the infant passed in both
ears on [**2191-7-15**].

6.  Psychosocial:  The parents have been involved in the
infant's care during his Newborn Intensive Care Unit stay.

DISCHARGE STATUS:  The infant is being discharged to the
Newborn Nursery.

CONDITION ON DISCHARGE:  His condition is good at the time of
discharge.

PRIMARY PEDIATRIC CARE:  Will be provided by Dr. [**Last Name (STitle) 43003**]
[**Name (STitle) 17494**] of [**Hospital3 **] Medical Center, telephone number
[**Telephone/Fax (1) 17663**].

CARE RECOMMENDATIONS:
1.  Feedings:  Enfamil 20 on an ad lib schedule.
2.  Medications:  The infant is discharged on no medications.
3.  A state screening has not been drawn yet.
4.  The infant has not yet received the hepatitis B vaccine.

DISCHARGE DIAGNOSIS:
1.  Resolved hypoglycemia
2.  Term male infant




                            [**Name6 (MD) **] [**Name8 (MD) 38353**], M.D.  [**MD Number(1) 38354**]

Dictated By:[**Last Name (NamePattern1) 37333**]
MEDQUIST36

D:  [**2191-7-15**]  01:36
T:  [**2191-7-15**]  02:18
JOB#:  [**Job Number 43004**]

ICD9 Codes: V053