history of present illness: this 40 5/7 weeks gestation infant, currently day of life #2, was admitted to the neonatal is a 32 year old gravida 3, para 1 to 2 woman with past obstetric history notable only for the spontaneous vaginal delivery of an infant who is now alive and well at three years of age. past medical history: the past medical history is unremarkable. family history: negative for bleeding diatheses. prenatal screens: blood group 0 positive, direct antibody test negative, hepatitis b surface antigen negative, rpr nonreactive, rubella immune, group b streptococcus negative. the estimated date of delivery was for an estimated gestational age of 40 and 5/7 weeks. membranes were ruptured four hours prior to delivery yielding clear amniotic fluid. there was no maternal fever or fetal tachycardia. she progressed to a spontaneous vaginal delivery under combined epidural and spinal anesthesia. the infant was unremarkable at delivery. tactile stimulation and bulb suctioning were provided. apgar scores were 8 at one minute and 9 at five minutes. initial examination was recorded as normal. in the regular nursery, the infant initially breastfed well and had normal vital signs. of note, vitamin k was administered. today on discharge examination, she was noted to be pale, somewhat more lethargic and less interested in breastfeeding. she was transferred to the neonatal intensive care unit for further evaluation. physical examination: on examination, the infant was very pale and moderately lethargic. birthweight was 3470 gm, head circumference 35 cm and length 51 cm. heartrate was 156, increasing to 180 or 190 with agitation. respiratory rate was 52 and oxygen saturation 100% in room air. blood pressure was 78/44 with a mean of 55. temperature 98.2 degrees. head, eyes, ears, nose and throat: the anterior fontanelle was soft and flat. facies were nondysmorphic and palate intact. the neck and mouth are normal. resp: there is no nasal flaring. there are no intercostal retractions. she has good breathsounds bilaterally with no crackles. cvs: she is pale but otherwise appears well perfused. she has regular rate and rhythm. femoral pulses are normal. first and second heartsounds are normal. there is a i/vi systolic ejection murmur at the lower left sternal border without radiation. abd: the abdomen is mildly distended with some resistance to palpation. there is no discoloration, no organomegaly, and no masses are noted. bowel sounds are active and the anus is patent. cns: the infant is slightly lethargic at baseline but responsive to stimuli. she is moving all extremities. tone is essentially normal. the suck, root, gag, grasp, and moro reflexes are all within normal limits. examination of the integument shows no ecchymoses or petechiae and the infant is nonicteric. msk: she has a normal spine, limbs, hips and clavicles. laboratory data: investigations, the white blood cell count is 15.1, with 62% polymorphonuclear leukocytes and 3% band cells. hematocrit was 19.2 and reticulocyte is pending at the time of this dictation. platelet count is 194. the infant's blood group is 0 positive and coomb's negative. maternal kleihauer is pending. placental pathology showed a question of chorionitis and a small infarct. the cranial ultrasound is normal. abdominal ultrasound shows a large amount of free intraperitoneal fluid. there is an irregular left upper quadrant mass, possibly consistent with a ruptured spleen. impression: this term infant presents with severe neonatal anemia, intraperitoneal fluid which is likely blood in light of the anemia, and an abnormal splenic ultrasound, suggesting the possibility of splenic rupture. of note, there is no history of either interpartum or neonatal trauma. hospital course: 1. respiratory - the infant has remained in room air throughout her admission. examination of the lungs is entirely within normal limits. 2. cardiovascular - the blood pressure has been stable since admission. one bolus of normal saline was given in light of the intermittent tachycardia with agitation. the cardiac murmur has not been further investigated, but is likely related to increased flow secondary to anemia. 3. fluids, electrolytes and nutrition - the infant was breastfeeding on ad lib, demand basis prior to transfer to the neonatal intensive care unit. since transfer, she has been placed npo in light of the abdominal findings. a peripheral intravenous line has been placed with d10/w running at 60 cc/kg/day. umbilical, venous and arterial access has been secured; radiographic confirmation of placement is pending. the capillary glucose has been within normal limits. 4. gastrointestinal - tube has been placed. abdominal radiographs to exclude free intraperitoneal air are pending. the surgical service has evaluated the infant and will continue management at . 5. hematology - a packed red blood cell transfusion of 20 ml/kg is currently in progress. acquired or inherited coagulopathies are remote possibilities in light of her well appearance and negative family history respectively. in addition the platelet count is normal. a coagulation profile has, however, been drawn, with results pending. 6. infectious disease - given the possibility of intestinal involvement and the placental pathology, we have also drawn a blood culture and started broad spectrum antibiotic coverage, for anticipated course of 48 hours pending clinical status and culture results. 7. neurologic and sensory - the infant has had a normal neurologic examination with the exception of mild lethargy. hearing screen was normal while she was in the newborn nursery. 8. social - i have updated the parents extensively regarding the infant's current status, diagnostic considerations, and our management plan. condition on discharge: guarded. discharge disposition: the infant will be transferred to neonatal intensive care unit for further evaluation, including a computerized tomography scan and possible surgical exploration. primary pediatrician: dr. medications on transfer: discharge diagnosis: as above. , m.d. dictated by: medquist36 d: 16:29 t: 17:33 job#: Procedure: Prophylactic administration of vaccine against other diseases Diagnoses: Need for prophylactic vaccination and inoculation against viral hepatitis Observation for suspected infectious condition Single liveborn, born in hospital, delivered without mention of cesarean section Other specified birth trauma Undiagnosed cardiac murmurs Congenital anemia Pallor Other specified hemorrhage of fetus or newborn