she was born at 1:38 p.m. on to a 28 year old g3 p1 to 2 mother. prenatal laboratory studies included blood type a positive, antibody negative, rpr nonreactive, rubella immune, hepatitis b surface antigen negative, gbs unknown. maternal history is notable for cardiomyopathy diagnosed after the last pregnancy and treated with digoxin and an ace inhibitor. maternal history is also notable for asthma, wpw syndrome and an asd repair as a child. this pregnancy was complicated by development of severe congestive heart failure approximately 1-2 weeks prior to delivery, resulting in maternal admission to the intensive care unit and aggressive diuresis and medical management. she was given a course of betamethasone, which was complete on . biophysical profiles of the fetus were reassuring throughout. secondary to concerns for maternal health, plans were made to deliver the infant by elective cesarean section. on , delivery was on the , to allow maternal care in cardiac intensive care unit, with cardiac surgery if needed. membranes were intact at the time of delivery, and there was no labor. the mother was on day 6 of macrobid for a urinary tract infection, and received 1 dose of cefazolin preoperatively. cesarean section was performed under general anesthesia. the infant emerged with poor tone and no respiratory effort. initial heart rate was 30-40s, increasing to 60-80s with positive pressure ventilation with bag and mask. chest movement was seen to be very limited with bag and mask. the infant was therefore intubated at approximately 45 seconds of life, with rapid improvement in aeration and increase of heart rate to greater than 100 with positive pressure via endotracheal tube. with continued positive pressure ventilation, there was gradual improvement in tone and color seen. surfactant at 5 cc was administered at approximately 4 minutes of life. at 10-15 minutes of life, the infant was placed on monitors and transferred to transport isolette. initial oxygen saturations were 100 percent on an fio2 of 100 percent. initial blood pressure had a mean of 34. the infant was transported to the and nicu via ambulance without incident. she was maintained on an simv of 22/5 at a rate of 30, with an fio2 weaned to 30-40 percent. after arrival in the nicu, uvc and uac was placed. blood gas was watched for further weaning and ventilatory support. mild hypotension was noted, and the infant was given 2 boluses of normal saline and then started on dopamine. physical examination on admission: weight 1050 grams (50th percentile), length 37.8 cm (50th percentile), head circumference 25.5 cm (between 25th and 50th percentile). temperature was 96.9 - 99 heart rate 140-160's, respiratory rate 50-70. general-extremly premature infant, hypotonic and quiet. normal appearing skin, anterior fontanelle open and soft, oral endotracheal tube in place. exam of lungs revealed retractions with poor aeration. cv exam with regular rate and rhythm and no murmur. abdomen was soft and nondistended, with no organomegaly. normal premature female genitalia. patent anus. spine intact, nl extremities and hips. hospital course by systems: 1. respiratory: the patient, as stated above, was intubated in the delivery room. she received surfactant x 2. the patient is currently intubated on settings of 20/5 at a rate of 18, with an fio2 of between 24/31 percent for the last 24 hours. she was started on caffeine on day of life 8 in anticipation of extubation. she has had no apneic spells noted. 2. cardiovascular: as stated previously, the patient did have some issues with hypotension, and shortly after birth received 3 normal saline boluses, then was begun on dopamine. maximum dopamine dose was 15 mcg/kg/minute. she was as off dopamine by day of life 3. on day of life #1, she had an echocardiogram which showed a moderate size pda, and therefore indomethacin was begun. on day of life #4, the murmur was heard again. echocardiogram was obtained, which showed a continued moderate sized pda, and therefore indomethacin was again given. the patient had a repeat echocardiogram done on day of life 8, which showed a very small and restrictive pda. she has been hemodynamically stable since. 3. fluid, electrolytes, nutrition: the patient was initially npo, with total fluids of 100 cc/kg/day. on day of life #7, enteral feedings of special care 20 were begun at 10 cc/kg/day. she is currently on total fluids of 150 cc/kg/day, and feeding of special care 20 at 20 cc/kg/day, with no plan today to advance. the patient initially had a uac and uvc in place. uac was discontinued on day of life #4. uvc was discontinued on day of life #7, and picc line was placed. 4. gastrointestinal: phototherapy was initiated on day of life #1 for a bilirubin of 4.1/0.2. maximum bilirubin was 4.8/0.3. phototherapy was stopped on day of life #8, and rebound bilirubin was 3.6/0.3. 5. infectious disease: blood culture and cbc were obtained on admission. the patient was started on ampicillin, gentamicin. cbc was benign, and blood culture was negative after 48 hours. therefore, antibiotics were discontinued. she has had no further infectious disease issues. 6. neurologic: head ultrasound was obtained on day of life #8 and was within normal limits. condition on discharge: fair. name of primary care pediatrician: unknown. care recommendations: 1. feeds at discharge are special care 20 at 20 cc/kg per day, with total fluids of 150 cc/kg/day, pn at 130 cc/kg/day. 2. medications. the patient is currently receiving caffeine. 3. state newborn screening is pending. 4. immunizations. the patient has received no immunizations. discharge diagnoses: 1. prematurity at 27-6/7 weeks. 2. pda status post indomethacin x 2. 3. respiratory distress syndrome. 4. hyperbilirubinemia, resolved. 5. rule out sepsis, resolved. , Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Arterial catheterization Other phototherapy Umbilical vein catheterization Diagnoses: Single liveborn, born in hospital, delivered by cesarean section Observation for suspected infectious condition Respiratory distress syndrome in newborn Neonatal jaundice associated with preterm delivery Chronic respiratory disease arising in the perinatal period 27-28 completed weeks of gestation Primary apnea of newborn Neonatal bradycardia Patent ductus arteriosus Hypotension, unspecified Other preterm infants, 1,000-1,249 grams Late metabolic acidosis of newborn