Medical Text: Admission Date:  [**2185-4-17**]       Discharge Date:  [**2185-5-2**]

Date of Birth:   [**2185-4-17**]       Sex:  F

Service:  Neonatology

HISTORY:  [**First Name4 (NamePattern1) 14552**] [**Known lastname **], twin #2, was born at 34-2/7 weeks
gestation to a 40-year-old gravida 3, para 2 now four woman
by spontaneous vaginal delivery.  The mother's prenatal
screens were blood type O+, antibody negative, rubella
immune, RPR nonreactive, hepatitis surface antigen negative,
and group B Strep unknown.  This pregnancy was achieved
in-[**Last Name (un) 5153**] fertilization resulting in dichorionic-diamniotic
twin.  The mother received betamethasone at 23 weeks
gestation due to cervical shortening.  The pregnancy was also
complicated with hypertension and urinary tract infection x2
with an unknown organism, and mother was also a chronic
smoker.

The labor ensued after spontaneous rupture of membranes 12
hours to delivery of twin #1.  This twin emerged vigorous.
Apgars were eight at one minute and eight at five minutes.
The birth weight was 2,125 grams, the birth length 44.5 cm,
and the birth head circumference 31.5 cm.  All parameters in
the 25-50th percentile for gestational age.

ADMISSION PHYSICAL EXAM:  Reveals a vigorous preterm infant.
Anterior fontanel is soft and flat.  Sutures are proximated.
Positive bilateral red reflex.  Mild subcostal-intercostal
retractions, and some positive grunting.  Breath sounds are
equal.  Heart was regular, rate, and rhythm, no rhythm.  Pink
and well perfused.  Soft abdomen with positive bowel sounds,
three vessel umbilical cord.  Normal preterm female
genitalia, femoral pulses +2, and a nonfocal neurological
examination.

HOSPITAL COURSE BY SYSTEMS:

Respiratory:  The infant initially had some grunting flaring
and retracting which resolved by a few hours of life.  She had
some occasional episodes of desaturation in the first two
days of life, and has had no further apnea, bradycardia, or
desaturation.  On examination, her respirations are
comfortable.  She has always remained on room air throughout
her NICU stay.

Cardiovascular:  The infant has remained normotensive
throughout her NICU stay.  There are no cardiovascular issues.

Fluids, electrolytes, and nutrition:  At the time of
discharge, her weight is 2,180 grams, her length is 45 cm,
and her head circumference is 31.5 cm.

Enteral feeds were begun on day of life #1 and advanced
without difficulty to full volume feeding by day of life #2.
At the time of discharge, she is eating on an adlib schedule
of 24 calories/ounce of breast milk or Enfamil and breast
feeding when the mother is present.

Gastrointestinal:  She had one bilirubin drawn on day of life
#3 that was total 6.4 and direct 0.3.  She never required
phototherapy.

Hematology:  At the time of admission, the hematocrit was
46.8.  She has never received any blood product transfusion
during her NICU stay.

Infectious disease:  [**Doctor First Name 14552**] was started on ampicillin and
gentamicin at the time of admission for sepsis risk factors.
The antibiotics were discontinued after 48 hours when the
blood cultures were negative, and the infant was clinically
well.

Neurology:  There are no neurological issues.

Audiology:  Hearing screening was performed with automated
auditory brain stem responses, and the infant passed in both
ears.

Psychosocial:  Parents were very involved in the infant's
care throughout their NICU stay.

The infant is being discharged in good condition home with
her parents.

PRIMARY PEDIATRIC CARE:  Will be provided by Dr. [**First Name4 (NamePattern1) 2048**] [**Last Name (NamePattern1) **]
in [**Hospital1 1562**], telephone #[**Telephone/Fax (1) 49156**].

CARE AND RECOMMENDATIONS AFTER DISCHARGE:
1. Feedings:  24 calories/ounce of breast milk or Enfamil and
breast feeding to maintain consistent weight gain.

MEDICATIONS:
1. Iron sulfate (25 mg/ml of elemental iron) 0.2 cc po q day.

The infant has passed the car seat oxygenation test.

State newborn screens were sent on [**4-21**] and [**2185-5-1**].  The
infant has not yet received any immunizations in our attempt
to keep the twins on the same immunization schedule and her
twin has not yet reached the 2 kg weight recommendation for
the first hepatitis B vaccine.

RECOMMENDED IMMUNIZATIONS:
1. Synagis RSV prophylaxis should be considered from [**Month (only) 359**]
through [**Month (only) 547**] 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 RSV season, with a
smoker in the household, or with preschool siblings, or 3)
with chronic lung disease.

2. 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.

FOLLOW-UP APPOINTMENTS FOR THIS INFANT:
1. The [**Hospital6 407**] of [**Hospital3 **], telephone
#1-[**Telephone/Fax (1) 46331**].
2. Lactation consultant at the Learning Center at [**Hospital1 **], telephone #[**Telephone/Fax (1) 47507**].

DISCHARGE DIAGNOSES:
1. Prematurity at 34-2/7 weeks.
2. Twin #2.
3. Status post transitional respiratory distress.
4. Sepsis ruled out.




                            [**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **], M.D.  [**MD Number(1) 37201**]

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

D:  [**2185-5-2**]  15:03
T:  [**2185-5-2**]  06:58
JOB#:  [**Job Number 49158**]

ICD9 Codes: 7742, V290