history of present illness: baby girl was born at 32 and 1/7 weeks gestation and admitted to the nicu with prematurity and respiratory distress. she was born at 10:42 a.m. on weighing 1775 grams, the product of a 32 and week twin gestation pregnancy to a 37 year-old, g3, p2 now 4 mother with an estimated date of confinement of . prenatal labs included blood type b positive, antibody negative, rpr nonreactive, rubella immune, hbsag negative, gbs unknown. this pregnancy was notable for mono/mono twin gestation, reportedly spontaneous, complicated by early cord entanglement, prompting admission at 25 weeks gestation. mother was treated with betamethasone at that time and had remained hospitalized with intensive monitoring. some signs of fetal distress have been noted over the past several days although ultrasound had been reassuring. the patient reached 32 weeks gestation and decision was made to proceed with cesarean delivery at that time, due to the increased risks of complications. mother had experienced occasional preterm contractions but was not in labor. the membranes were intact at delivery and the mother did not receive intrapartum antibiotic prophylaxis. the maternal history was otherwise non contributory and the family is intact. at delivery, this infant emerged with good tone, cry and required stimulation and blow-by oxygen only. occasional apnea was noted in the delivery room which required positive pressure ventilation. the infant was brought to the nicu for further management. physical examination: physical examination on admission showed a birth weight of 1775 grams which is 50th percentile. head circumference of 30.5 cm which is 50th to 75th percentile. length of 42 cm which is 25 to 50th percentile. the infant was warm and dry, premature infant in mild to moderate distress at rest. active with examination and mildly reduced spontaneous activity. heent showed fontanel soft and flat. nares normal. intact palate. neck: supple, no lesions. chest: coarse breath sounds, mildly aerated, mild to moderate retractions, mild grunting. work of breathing less with cpap. cardiac: normal rate and rhythm, no murmur. abdomen soft, no hepatosplenomegaly, no mass, 3 vessel cord, quiet bowel sounds. genitourinary: normal female, patent anus. femoral pulses 2+. extremities, hips, back normal. neuro: appropriate tone, mildly reduced activity. moves all extremities well. hospital course: respiratory: the infant was started on cpap on admission to the nicu and remained on cpap until when the infant then successfully transitioned to nasal cannula oxygen. she subsequently transitioned to room air by and has remained on room air since that time. she was started on caffeine citrate for apnea of prematurity on and remains on caffeine citrate at this time. she continues to have occasional apnea and bradycardiac episodes, anywhere from 1 to 5 per day, typically mild self-resolved spells. breath sounds are clear and equal and mild to slight retractions are noted. cardiovascular: the infant received a single normal saline bolus for perfusion on admission to the nicu. a murmur presented on day of life and subsequently resolved. the murmur reappeared on . a duct check was done. echocardiogram duct check was done at that time which showed a moderate sized pda 2 mm in size. the murmur subsequently resolved within a couple of days, due to the fact that the infant was stable on room air at the time of the murmur. no indomethacin was given. the murmur has subsequently resolved and a repeat duct check was done on which showed no pda at that time. she has remained cardiovascularly stable with normal heart rates and blood pressures throughout. fluids, electrolytes and nutrition: the infant was made n.p.o. on admission to the nicu due to the mild respiratory distress. peripheral iv was placed and iv fluids were initiated at that time. enteral feedings were initiated on which was day of life 2. they were subsequently advanced. she was made n.p.o. when her murmur presented on due to concern for a pda. she remained n.p.o. for 3 days at that time, at which time a follow-up duct check had shown there was no pda and enteral feedings were reinitiated at that time. at the time when the murmur presented, she did have a small bilious emesis. those had resolved prior to reinitiation of feeds, when her feedings were then reinitiated on . they were further advanced to full volume feedings. she achieved full volume feedings by . she has had intermittent large emesis requiring decrease in total fluids to 140 ml per kg per day. she is presently on 140 ml/kg/day of 22 calorie breast milk or special care. she does receive that over 1-1/2 hours to 2 hours to decrease spits. her most recent weight is 1835 grams. her most recent set of electrolytes were done on . sodium 137; potassium of 4.6; chloride 103; c02 of 23. she is not on any electrolyte supplementation. gastrointestinal: the infant developed hyperbilirubinemia and had a peak bilirubin level of 8.8 over 0.3. she received a total of 5 days of phototherapy. her most recent bilirubin level was 7.0 over 0.3 on . she had a repeat bilirubin done on . the result is 7.4/0.4. hematology: a hematocrit at birth was 41.2 with a platelet count of 207. there have been no further hematocrits or platelets measured. the infant has not had any blood typing done. infectious disease: cbc and blood culture were screened on admission to the nicu, due to the respiratory distress and prematurity. the cbc was benign with no left shift. the infant was initiated on ampicillin and gentamycin which were subsequently discontinued at 48 hours of age when the blood cultures remained negative at that time. there had been no further issues with sepsis. neurology: the infant has maintained a normal neurologic exam for gestational age. a single head ultrasound was done on and found to be within normal limits with no intraventricular hemorrhage. audiology: a hearing screen has not been performed but will need to be done prior to discharge to home. psychosocial: a social worker has been in contact with the family. there are no active issues but, if there are any concerns, she can be reached at . condition on discharge: stable discharge disposition: transfer to level ii nursery at . name of primary pediatrician: , md, pediatrics, telephone number . cardiac assessment: pg feeds with transition to p.o. feedings, to initiate soon, at 140 ml per kg per day of breast milk 26 or special care 26 with beneprotein, gavage fed over 90 min for spits. medications: iron and vitamin d supplementation. 1. iron supplementation is recommended for preterm and low birth weight infants until 12 months corrected age. 2. all infants fed predominantly breast milk should receive vitamin d supplementation at 200 i.u. (may be provided as a multi-vitamin preparation) daily until 12 months corrected age. 3. car seat position screening will need to be done prior to discharge to home. 4. state newborn screen was sent on day of life 3. results are pending. immunizations: the infant has not received any immunizations thus far. immunizations recommended: synagis rsv prophylaxis should be considered from through for infants who meet any of the following four criteria: (1) born at less than 32 weeks; (2) born between 32 weeks and 35 weeks with two of the following: day care during rsv season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings; (3) chronic lung disease or (4) hemodynamically significant congenital heart disease. influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. before this age, and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. this infant has not received rota virus vaccine. the american academy of pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable or at least 6 weeks but fewer than 12 weeks of age. followup: follow-up appointment will need to be made with the pediatrician after discharge from the hospital. discharge diagnoses: 1. prematurity. 2. sepsis, ruled out. 3. respiratory distress, resolved. 4. patent ductus arteriosus resolved without treatment. 5. hyperbilirubinemia, resolving. 6. transient hypovolemia, treated. , md Procedure: Parenteral infusion of concentrated nutritional substances Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Other phototherapy Diagnoses: Observation for suspected infectious condition Twin birth, mate liveborn, born in hospital, delivered by cesarean section Respiratory distress syndrome in newborn Neonatal jaundice associated with preterm delivery Primary apnea of newborn Neonatal bradycardia Patent ductus arteriosus Other preterm infants, 1,750-1,999 grams 31-32 completed weeks of gestation Other transitory neonatal electrolyte disturbances