history of present illness: baby boy #1 is first triplet admitted at 33-6/7 weeks' gestation for prematurity management. maternal history: thirty-five years old, gravida 2, para 1, woman with past medical history noted for full-term svd. she also had epilepsy is on lamotrigine and lorazepam. she also had postpartum depression. family and social history is noncontributory. prenatal screens: blood type o+, antibody negative, hepatitis b surface antigen negative, rpr nonreactive, rubella immune, gbs negative. antenatal history: , by ivf dating for estimated gestational age of 33-6/7 weeks at delivery. pregnancy was complicated by iugr with all 3 triplets measured at less than 10th percentile. for this she underwent an elective cesarean section under epidural and spinal anesthesia. she completed a course of betamethasone. there was no labor and no antepartum fever, and there was no clinical evidence of chorioamnionitis was noted. intrapartum antibiotic therapy was not administered. neonatal course: the infant was vigorous at delivery. he was orally and nasally bulb suction, dried and was subsequently pink in room air with very mild grunting respiration noted. apgar scores were 9 at one minute and 9 at five minutes. physical examination: preterm infant with examination consistent with 34 week gestational. birth weight g, 50th percentile, ofc, 31.5 cm, 50th percentile, length 44 cm, 25-50th percentile. anterior fontanel straight and flat. nondysmorphic. palate intact. neck moves normal. mild nasal flaring. chest: minimal intercostal retractions, good breath sounds bilaterally. no adventitious sounds. cvs: well perfused. heart rate and rhythm regular. femoral pulses normal. s1 and s2 normal. no murmur. abdomen: soft, nondistended, no organomegaly, no masses. bowel sounds active. there was a three-vessel umbilical cord. genitourinary: normal phallus. testes descended bilaterally. cns: active, alert, responds to stimuli. tone aga and symmetry. moves all extremities well. suck, root, gag intact. facies symmetric. msk: normal spine, limbs, hips, clavicles. physical examination at discharge: discharge weight 2480 g. heent: anterior fontanel open and flat. pupils equal and reactive to light and normal retroflex present bilaterally. clavicles intact. neck supple. nares patent. oral mucosa is pink. respiratory system: mild subcostal retractions. chest clear to auscultation bilaterally with good air entry. cvs: rate and rhythm are regular. normal s1 and s2 with a short systolic murmur at left sternal border with no radiation. femoral pulses equal. brachial pulses 2+. abdomen soft, nondistended. no visceromegaly. bowel sounds present. neurologic: alert and active. tone and aga normal and reflexive . spine straight. genitalia normal circumcised male. testes descended bilaterally. skin intact. extremities: hips stable. hospital course: respiratory: he was initially placed on nasal cpap for the first day due to some mild respiratory distress. the chest x-ray was consistent with mild atn with no rds. he was weaned to room air on second day of life and remained room air breathing, stable clinically until the day of discharge. he was noted to have occasional apnea and bradycardia episodes, most of the time with feeding and self- resolved. his last apnea and bradycardia episode was on , on day of life 17, and after that he remained hemodynamically stable with no further episodes. cvs: an intermittent systolic murmur was noted on on day of life 18 and persisted through the day of discharge. a cardiology evaluation was performed on . his chest x- ray was consistent with normal cardiac shadow with normal and clear lungs. ekg was normal. his 4 extremity blood pressures and pre and post oxygen saturations were reported as normal. further clinical follow-up by the pediatrician is recommended. fen: he was npo until the second day of life and was started on intravenous fluids and he continued on intravenous fluids until day of life 6. feedings with pe 20 kcal/oz was introduced on second day of life and was advanced. he received full feeds of p.o. and pg feeds on day of life 8. calories were advanced 24 kilocalories/oz on day of life 9. the formula was changed to similac 24 kcal/oz on day of life 23 due to the availability of this formula at home. he started taking full p.o. feeds ad lib demand from day of life 22 until day of discharge. gi: his maximum serum bilirubin was 6.5/0.4 on day of life 5. he did not receive any phototherapy. genitourinary: he was circumcised on , and the site has healed well. hematological: his initial cbc at birth was noted for a white blood cell count of 9.6, hematocrit 47 and platelets 320. there were 16 neutrophils but no bands. he was started on ferrous sulfate supplementation from day of life 10 which was discontinued on day of life 16. his last hematocrit was performed on day of life 23 on , and it was 34.7 with a reticulocyte count of 2.5. id: he was initially started on ampicillin and gentamicin at birth. cultures were negative at 48 hours and antibiotics were discontinued. neurology: the patient's gestational age more than 32 weeks does not qualify for any screening head ultrasound examination. ophthalmology: not examined because the patient's gestational age is more than 32 weeks and does not qualify for ophthalmologic examination. psychosocial: social work involved with the family. the contact social worker was reached at . condition on discharge: stable. discharge disposition: home. name of primary pediatrician: dr. . care recommendations at discharge: feeds at discharge: similac 24 kcal/oz p.o. ad lib on demand. medications: none. 1. iron supplementation is recommended for preterm and low birth weight infants until 12 months corrected age. 2. all infants that are predominantly on breast milk should receive vitamin d supplementation at 200 international units. be provided as a multivitamin supplementation, daily until 12 months corrected age. car seat position screening: passed. state newborn screening status: , and normal. immunizations received: none. hepatitis b vaccine will be given at the pediatrician's office. immunizations recommended: 1. synagis rsv prophylaxis should be considered from through for infants who meet any of the following 4 criteria: 1) born at less than 32 weeks, 2) born between 32 and 35 weeks with 2 of the following: day care during rsv season, a smoker in the household, neuromuscular disease, airway abnormalities, or school- age siblings, 3) with chronic lung disease, or 4) hemodynamically significant congenital heart disease. 2. 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. 3. this infant has not received rotavirus vaccine from american academy of pediatrics recommend initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable and at least 6 weeks but fewer than 12 weeks of age. follow-up: dr. on . discharge diagnosis: 1. prematurity at 33-6/7 weeks' gestation. 2. triplet gestation, triplet #1. 3. mild respiratory distress at birth. 4. intermittent cardiac murmur. Procedure: Parenteral infusion of concentrated nutritional substances Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Circumcision Diagnoses: Primary apnea of newborn Neonatal bradycardia Other specified conditions originating in the perinatal period Other preterm infants, 2,000-2,499 grams Routine or ritual circumcision 33-34 completed weeks of gestation "Light-for-dates" without mention of fetal malnutrition, 2,000- 2,499 grams Transitory tachypnea of newborn Other multiple birth (three or more), mates all liveborn, born in hospital, delivered by cesarean section Undiagnosed cardiac murmurs