history of present illness: baby girl is a gram infant born at 33 weeks to a 34 year old gravida ii, para i, now ii mother. the mother's previous medical history is notable for asthma requiring prn albuterol and a blood transfusion in , for abruption related hemorrhage. mother had a previous cesarean section at term in , following cerclage placement for cervical shortening. this pregnancy was complicated by cervical shortening which did not require a cerclage. it was also complicated by placental abruption at 24 weeks. mother got packed red blood cell transfusion and betamethasone at that time. prenatal screens include a blood type o positive, antibody negative, rubella immune, rpr nonreactive, hepatitis b surface antigen negative, and gbs status unknown. the mother represented with spontaneous preterm labor and a recurrence of abruption related hemorrhage and was delivered by repeat cesarean section under spinal anesthesia. ruptured membranes was at the time of delivery. there was no maternal fever. she had not received intrapartum antibacterial prophylaxis. at delivery, the infant was vigorous and required only blow by oxygen resuscitation. apgar was eight at one minute and eight at five minutes of life. she was admitted to the neonatal intensive care unit for management of her prematurity. physical examination: on admission, birth weight was grams, 50th percentile, head circumference 30 centimeters, 25th to 50th percentile, length 44 centimeters, 50th percentile. in general, the infant was a well appearing infant in no acute distress. head, eyes, ears, nose and throat examination revealed anterior fontanelle soft and flat, nondysmorphic facies, intact palate, moist mucous membranes, normocephaly and minimal nasal flaring. chest examination revealed no retractions but intermittent very mild grunting respirations with agitation. the patient had good breath sounds bilaterally and no crackles. her heart was regular rate and rhythm with no murmur. her femoral pulses were two plus and her perfusion was good. her abdomen was soft, nondistended without mass, with active bowel sounds. she had a three vessel umbilical cord. her anus was patent. her genitalia were consistent with normal preterm female. her skin was normal. her spine showed no clefts, or dimples. her hips were stable. her clavicles were intact. her neurologic examination revealed an active, alert infant, responsive to stimulation with appropriate tone. she moved all extremities well and had an intact suck, root and gag reflex. her grasp was symmetric. hospital course: respiratory: baby girl transitioned well after delivery and has been in room air during her entire hospital stay. she had one episode of isolated bradycardia without desaturation on day of life four and has had no other apneic or bradycardia spells. she has not required treatment with caffeine. cardiovascular: baby girl been hemodynamically stable throughout her stay with normal perfusion and blood pressure. no murmur was noted on her initial examination, but on day of life six, a ii/vi systolic murmur was noted. echocardiogram at that time revealed a small patent ductus arteriosus that was 1.0 millimeter with a 40 mmhg gradient across it, all left to right flow. it also noted mild left sided peripheral pulmonic stenosis. this small patent ductus arteriosus is expected to resolve spontaneously. fluids, electrolytes and nutrition: on admission, baby girl was held npo and placed on intravenous fluids at 80 cc/kg/day. at 24 hours of age, she was begun on nasogastric feedings of breast milk or special care 20. these were advanced and her total fluids were advanced to her current feeding schedule of breast milk or special care 24 calories per ounce, currently all nasogastric, at 150 cc/kg/day. the infant voids and stools appropriately. her electrolytes were normal at 24 hours of life. hematologic: baby girl initial hematocrit was 50.9 percent. she has required no blood products during this admission. her peak bilirubin was 6.2 on day of life three with a most recent bilirubin of 5.3 on day of life six. she never required phototherapy. infectious disease: in light of mother's unknown group b strep status and preterm labor, a sepsis evaluation was undertaken on admission. initial complete blood count revealed a white blood cell count of 14.6 with 32 percent polys and no bands. platelet count was 292,000. she was begun on ampicillin and gentamicin. antibiotics were discontinued at 48 hours when cultures were negative. sensory: hearing screen has not yet been performed, but is recommended prior to discharge. condition at interim summary: good. primary pediatrician: dr. of pediatrics. care/recommendations: 1. feeds at the time of the interim summary are breast milk or special care 24, all nasogastric, at 150 cc/kg/day. 2. baby girl is on no medications. 3. car seat position screen has not yet been performed but is recommended prior to discharge. 4. state newborn screen has been sent. 5. hepatitis b vaccination has not yet been given but is recommended prior to discharge. 6. immunizations recommended - synagis rsv prophylaxis should be considered from through for infants who meet any of the following three criteria: born at less than 32 weeks, born between 32 and 35 weeks with two of the following: daycare during rsv season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings or with chronic lung disease. influenza immunization is recommended annually in the fall for all infants once they reach six 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. discharge diagnoses: prematurity at 33 weeks gestation. small patent ductus arteriosus. immature feeding. rule out sepsis-resolved. , Procedure: Diagnostic ultrasound of heart Prophylactic administration of vaccine against other diseases Diagnoses: Single liveborn, born in hospital, delivered by cesarean section Need for prophylactic vaccination and inoculation against viral hepatitis Observation for suspected infectious condition Patent ductus arteriosus Other preterm infants, 1,750-1,999 grams 33-34 completed weeks of gestation