DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
HISTORY OF PRESENT ILLNESS: The patient was born by a normal spontaneous vaginal delivery to a (XX)-year-old female, G1, P0, blood type AB+, GBS negative, hepatitis B negative, HIV negative, rubella immune, VDRL nonreactive mother who denied any tobacco, alcohol or drug use during pregnancy.
HOSPITAL COURSE: The baby was delivered at 39 weeks gestational age with a three-vessel cord and Apgars of 7 and 8. DeLee suction was used as well as blow-by O2. Mother did get Nubain during labor. Birth weight was 2825 grams.
The child began, shortly after birth, having some grunting, retractions, and was admitted to Special Care Nursery. While in Special Care Nursery, the following issues were addressed.
1. Nutrition. The child was originally n.p.o. with IV fluids of D10W running at 10 mL per hour. Hyperalimentation was begun on MM/DD/YYYY. NG bolus feeds were started on MM/DD/YYYY at 15 mL q. 3 hours. The child was again made n.p.o. on MM/DD/YYYY with having some desaturations. The hyperalimentation was continued at this point in time. Feeds resumed on the next day at 10 mL q. 3 hours, and as feeds were able to be advanced, the IV fluids and hyperalimentation were decreased. The child underwent an ENT procedure on MM/DD/YYYY and was made n.p.o. on that date. Feeds were resumed later in the day after the procedure by p.o. and NG bolus. The child had poor toleration of feedings, and the NG bolus feeds were needed a substantial amount of the time.
2. Gastroesophageal reflux disease. The patient was having multiple episodes of spitting up of food and not tolerating p.o. feeds very well. Reglan was started, and later, by recommendation of the ENT, Prevacid was begun.
3. Subglottic stenosis. ENT procedure on MM/DD/YYYY. Bronchoscopy performed by Dr. John Doe showed some subglottic stenosis, likely due to acid reflux. He recommended Prevacid, and the Reglan was continued.
4. Respiratory distress. The child was intubated on the day of admission and was given Narcan. The patient was extubated the next day and placed on nasal cannula. There were some low saturations, which followed in the nasal CPAP at +5. FiO2 50% was started and saturation improved. The CPAP was removed in the morning and tolerated well. On MM/DD/YYYY, the child began having some desaturations, and oxygen by nasal cannula was started at 1/16th of a liter.
5. Increased bilirubin. Bilirubin levels seemed to be elevated on MM/DD/YYYY and single phototherapy was begun on that day.
6. Sepsis. The patient received ampicillin and gentamicin for 5 days worth of 10 doses of ampicillin, and blood cultures remained negative.
7. Poor tolerating of feeds and low tone of the child. Pediatric Neurology was involved because of both poor tolerating of feeds and low tone of the child. MRI was performed without sedation on MM/DD/YYYY with results showing no evidence of brain parenchymal or structural abnormalities.
8. Talipes equinovarus. PT and Orthopedics were consulted concerning this issue. There were multiple episodes of ankle stretching, and they recommended further treatment as an outpatient.
9. Factor for anemia. H&H levels are 15 and 43.
10. Need for auditory evoked response test. The patient passed the AER.
PHYSICAL EXAMINATION ON DISCHARGE:
VITAL SIGNS: Stable.
HEAD: Anterior fontanelle was soft and flat.
LUNGS: Clear.
HEART: There was no murmur.
ABDOMEN: Soft and nondistended.
DISCHARGE DISPOSITION: The patient was discharged to home with parents.
DISCHARGE INSTRUCTIONS:
1. Discharged to home with apnea monitor.
2. Feeds, 45 to 60 mL q. 3-4 hours, either p.o. or NG bolus.
3. Continue the Prevacid and Reglan as prescribed.
4. Visiting nurse will be coming twice a week for two months.
5. Follow up with Dr. Jane Doe in one week.
6. Follow up with Neonatal High-Risk Clinic.
7. Also, get OT/PT as an outpatient.
