service: neonatology history of present illness: is a 37 week gestational age male admitted to the neonatal intensive care unit with a cardiac murmur and dysmorphic features. maternal history: this is a 35 year-old gravida 2 para 0 now notable for spontaneous abortion. past medical history and family history is unremarkable. no medications. prenatal screens: blood type a positive, antibody negative, rpr nonreactive, rubella immune, hepatitis b surface antigen negative, group beta strep negative. an afp was not performed during the pregnancy. pregnancy history: last menstrual period on for an estimated date of delivery of and estimated gestational age of 37 weeks. no testing was performed for advanced maternal age. this pregnancy was complicated by elevated glucose with normal glucose tolerance test controlled with diet. ultrasound one week prior to delivery showed bilateral renal dilatation and cerebral ventriculomegaly. membranes were ruptured seven hours prior to delivery yielding clear amniotic fluid. no maternal fever or fetal tachycardia. this was a spontaneous vaginal delivery under epidural anesthetic. the infant received tactile stim and bulb suctioning in the delivery room. apgars were 7 at one minute and 8 at five minutes of age. dysmorphic features were noted in the delivery room. neonatology consultation requested to exclude syndrome. following transfer to the neonatal intensive care unit oxygen saturations were noted to be 88 to 90% in room air. physical examination: weight 2440 grams (10 to 25th percentile). head circumference 30 cm (less then 10th percentile). heart rate 118. respiratory rate 48. oxygen saturation room air 88%. four extremity blood pressures right arm 63/38 with a mean of 51, left arm 56/34 with a mean arterial pressure of 39, right leg 54/38 mean arterial pressure of 48 and left leg 60/34 with a mean arterial pressure of 44. head anterior fontanel soft and flat. epicanthal folds with up slanting palpebral fissures, palette intact. no macroglossa, no nasal flaring, some nuchal redundancy, skin tag to the right maxilla. chest, no retractions and no grunting. good breath sounds bilaterally. no crackles. heart infant well perfused. regular rate and rhythm. pulses normal, symmetrical. s1 and s2 normal. grade 2/6 systolic murmur at left lower sternal border radiating across precordium. abdomen soft, nondistended. no organomegaly, no masses, bowel sounds active, patent anus. genitourinary, normal male genitalia, testes descended bilaterally. skin normal. neurological infant responsible to stimuli, but slight decreased activity. tone decreased in symmetrical distribution. moving all extremities. suck, root, gag, grasp and marrow normal. a single palmar crease was noted. normal spine. hips stable and clavicles intact. hospital course: 1. respiratory: has been in room air throughout his hospitalization with oxygen saturations ranging from 88 to 95%. his last gas at 11:30 on ph of 7.4, pco2 40, po2 56, bicarb 26, base excess of 0. 2. cardiovascular: shortly after admission to the neonatal intensive care unit a cardiac evaluation was performed with consultation from cardiology. an echocardiogram revealed tetralogy of fallot with mild subpulmonic pulmonary stenosis, mildly small pulmonary valve, a small pda and low velocity flow suggesting pvr still high. the infant's blood pressure has been stable throughout his hospitalization. he has not required fluid boluses or pressors for blood pressure support. cardiology has been involved and is following. 3. fluid, electrolytes and nutrition: upon admission to the neonatal intensive care unit intravenous fluids of d10w were initiated at 80 cc per kilo per day. the infant appeared well and did receive several feedings on day of life one without incident. on the evening of day of life one the infant's abdomen was noted to be distended. a kub was done, which showed diffuse distended loops of bowel throughout. the infant was transferred over the for a lower gi study. a scout film upon arrival to revealed diffuse pneumatosis on the x-ray and the infant was transferred back to not having had the lower gi performed. the infant was made npo at that time. tube was placed. triple antibiotics were initiated. the infant is currently on ampicillin, gentamicin and clindamycin. kubs were performed every six hours throughout the night of . abdominal ultrasound at 6:00 a.m. revealed free air over the liver and surgery was contact. sticks have remained stable throughout his hospitalization. he has passed meconium stool. the last meconium stool was passed on the morning of and was grossly guaiac positive. last set of electrolytes was drawn on at 6:00 a.m. and those electrolytes are pending. electrolytes from at 11:30 p.m. showed a sodium of 131, potassium of 5.5, chloride 96 and total co2 of 22. bilirubin at that time was a total of 10.5 and a direct of 0.5. is currently receiving d10w at 60 cc per kilo per hour with 2 meq of sodium and 1 meq of potassium per 100 cc. his weight on was 2350 grams. 3. hematology: 's last hematocrit at 11:30 p.m. on was 50. he has not received any blood products during his hospitalization. 4. infectious disease: on the infant had a cbc with blood cultures drawn. hematocrit at that time 57 with a white blood cell count of 11.6, platelet count of 179 with 70% neutrophils and 14% bands. a blood culture was drawn at that time as well and is negative to date. a repeat cbc was drawn on with a white blood cell count of 9.400, hematocrit 50 and a platelet count of 110 with 65% neutrophils and 14% bands. the infant is currently on ampicillin, gentamicin and clindamycin. 5. neurology: a prenatal ultrasound revealed cerebral ventriculomegaly. a head ultrasound done on revealed mild prominence of the atriums of the lateral ventricles and suggestion of vermian hypoplasia. neurology service has been consulted with these findings and an mri has been recommended to follow up on these findings. 6. renal: prenatal ultrasound showed bilateral renal dilatation. a renal ultrasound on revealed mildly dilated renal pelvises. a repeat renal ultrasound or vcug has been recommended for future follow up. 7. skin: plastics have consulted on the skin tag to the right maxilla. 8. sensory: a hearing screen has not been performed at this time. 9. genetics: chromosomes were sent with fish 21 shortly after admission to the neonatal intensive care unit. the results of this test revealed trisomy 21. final chromosomal report is pending. an ophthalmologic examination was not indicated for this 37 week infant. 10. psycho/social: social worker has been involved with the family. the contact social worker is . she can be reached at . condition on transfer: the infant is stable in room air, positive free air noted on kub at 6:00 a.m. blood pressure stable. discharge disposition: to via ambulance. name of primary pediatrician: pediatrics. care and recommendations: state newborn screen at 72 hours of age, no abnormal results have been reported at this time. immunizations, the infant has not received any immunizations. follow up appointments: dr. from the ch genetics service will be following this infant. phone number . will also be followed by the clinic at . will need a repeat renal ultrasound or vcug will be needed for renal follow up. an mri has also been recommended by neurology for follow up of the vermian hyperplasia. discharge diagnoses: 1. term infant with trisomy 21. 2. tetralogy of fallot. 3. microcephaly. 4. necrotizing enterocolitis. 5. vermian hypoplasia by head ultrasound. 6. renal dilatation by renal ultrasound. , m.d. dictated by: medquist36 d: 08:10 t: 08:55 job#: Procedure: Reconstruction of eyelid with hair follicle graft Other local excision or destruction of lesion or tissue of skin and subcutaneous tissue Diagnoses: Single liveborn, born in hospital, delivered without mention of cesarean section Tetralogy of fallot Unspecified fetal and neonatal jaundice Down's syndrome Microcephalus Prader-Willi syndrome Other specified disorders of kidney and ureter