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Discharge Diagnosis: Liveborn infant, of singleton pregnancy, born in hospital by cesarean delivery Extreme prematurity, 545 grams, 26 completed weeks of gestation; Congenital hypothyroidism Anemia in prematurity IUGR of newborn Apnea of prematurity Bronchopulmonary dysplasia (BPD) and aspiration pneumonia Patent ductus arteriosus Atrial septal defect Neonatal jaundice Neonatal hypoglycemia Admission History & Physical Exam: Patient is the 545-gram product of a 26-week gestation delivered by urgent C-section to a 28year old G2, P1 blood type A, Rh positive, Rubella immune, Serology nonreactive, Hepatitis B negative, Hepatitis C negative, HIV negative, GBS unknown, married, Caucasian, female. Assigned Apgar scores were 1 at one minute, and 9 at five minutes. Delivery was complicated by preeclampsia with severe features, IUGR <5th percentile, and variable decelerations. Prenatal therapies included Betamethasone (2 doses; delivery was 5 hours before full steroid benefit was achieved). Delivery was emergent and uncomplicated. The infant was passed through the delivery window. Infant demonstrated spontaneous respirations but required intubation for respiratory failure and bradycardia. Hospital Course:FEN/GI: Mariah was initially started on fluids via a UVC and UAC. We monitored her glucose levels regularly and made adjustments as needed. The UAC was removed on 6/2 and the UVC was removed on 6/3. A PICC line was inserted on 6/3 and removed 6/15. TPN and lipids provided nutrition via NG tube until full feeds were achieved on 6/15 with EBM fortified to 24 kcal. Full feeds EBM fortified to 27 kcal and given over 90 minutes due to hypoglycemia episodes. She was continued on full feeds and they were condensed to 30 minutes without episodes of hypoglycemia. We slowly introduced her to PO feeds which she tolerated well. We allowed her to PO feed ad lib and NG feed what was left from her goal volume. Prior to discharge, we removed her NGT and did well with all PO feedings. RESP: She was intubated immediately after birth and put on HFOV and given surfactant x1. Chest X-rays were obtained and Vitamin A and Caffeine were started. She was extubated the following day, however due to persistent abdominal distension and the fact that no bowel movement occurred, we reintubated her on 6/6 and she remained intubated until 7/2. Extubated to SiPAP and then transitioned to CPAP, HFNC and then eventually to LFNC. She was discontinued from her caffeine but because of increased apnea and bradycardic events with intermittent tachypnea and desaturations she was re-started on her caffeine. She started developing respiratory distress on 8/15 after it was thought she aspirated and she required re-intubation. She was able to be extubated successfully the next day and put on CPAP. A chest x-ray was rechecked on 8/20 which showed improved aeration of the lung fields so Mariah was trialed on LFNC 0.025L. CV: On 6/6, a murmur was auscultated and an echocardiogram was done that showed a moderate PDA, for which we treated with Tylenol. A repeat echocardiogram showed mild improvement. A second 3-day treatment course with Ibuprofen was given and another repeat echo on 6/23 still showed physiologically significant PDA. We continued to monitor CV status clinically. Had PDA ligation surgery on 6/30 without complications. Post-operative ECHO showed mild LA dilation and mild LV dilation with LV systolic function qualitatively normal. Follow-up TTE 8/5 showed mild LA and LV dilation and possible PFO with tiny atria left to right shunt. She will follow-up with Pediatric Cardiology. GI: Initially, bilirubin levels were elevated and phototherapy was initiated. Levels were followed until phototherapy was discontinued. Direct hyperbilirubinemia was noted and many etiologies were considered, however we suspected TPN cholestasis as direct and total bilirubin levels decreased once TPN was discontinued. At birth, she failed to pass meconium and her abdomen was distended. Surgery was consulted and a bedside barium enema was done with serial x-rays. Her first spontaneous bowel movement was on DOL 13. Once we started regular feeds, she continued to have regular bowel movements with no issues. HEME: Hemoglobin levels were followed and a transfusion of pRBC and platelets were given on 6/5. Subsequent transfusions of pRBC were given 6/4, 6/7, 6/10, 6/18, 6/24, 6/30, 7/12, 7/16. Labs have been normal until discharge NEURO: IVH precautions were initiated with Brainy bunch protocol and Indomethacin prophylaxis was given. A HUS on DOL 7 was obtained which was normal. Repeat HUS was done at 5 weeks of life, which was reported as normal. ROP at 5 weeks of age showed OD and OS: Stage 0, zone 1 posterior. 2-week follow up ROP on 7/21 showed immaturity. ROP follow-up on 8/17 and 9/1 also showed immaturity. She has a follow-up appointment with Ophthalmology on 09/15. Initially in isolette with humidity which was weaned per protocol to skin temp. Tolerated wean to air temp rapidly given CGA of 33 and diagnosis of BPD. Air turned off and with stable temperatures transitioned to bassinet. ID: On DOL 4, ANC was noted to be low and a 3-day course of Neupogen was given. Nafcillin and Gentamicin were given for 4 days to rule out infectious etiology that may have contributed to GI issues. Another course of antibiotics for 5 days starting on 6/17. Pan cultures were negative. She began having respiratory distress and feeding intolerance with bilateral lobe infiltrates and was started on Nafcillin, Gentamicin, and Clindamycin with concerns of aspiration pneumonia. She had a full sepsis work-up including blood, urine, and CSF. These showed no growth and Nafcillin and Gentamicin was discontinued at 48 hours and Clindamycin was continued for a 7 days total. ENDO: Infant had abnormal newborn screen with low T4 and elevated TSH. T4 and TSH trended weekly. She was started on Levothyroxine 13 mcg and increased to Levothyroxine 18.75mcg daily. Repeat TSH and free T4 were normal. She continued to have hypoglycemia so critical labs of cortisol, insulin, and glucose were obtained and showed hyperinsulinism. She was started on diazoxide but started to have fluid overload so she was started on HCTZ. When she had an aspiration pneumonia her diazoxide and Hctz were discontinued and her sugars remained stable. She will follow-up with Pediatric Endocrinology on 09/17. BONE: She was started on sodium phosphate and CXR from 8/18 showed possible rachitic rosary concerning for Rickets. A vitamin D level was obtained and it was not concerning. Alkaline phosphatase and phosphorus levels were followed during admission and remained stable. Maternal History: Past Medical History: Wolf-Parkinson-White and morbid obesity Past Surgical History: Previous cesarean delivery Family History: Not Available Social History: Not Available Vitals: Temperature: 98.5°F Pulse: 150 Blood Pressure: 35/28 Head Circumference: 22cm Weight: 0.545kg (1lb 3.2 oz) Physical Examination: General: alert, active, pink, and well perfused, comfortable on mechanical ventilation, no distress HEENT: anterior fontanel open, soft and flat, ears normally formed and positioned, eyelids fused bilaterally, orally intubated and mucous membranes clear and moist Neck: supple without masses, clavicles intact without crepitus Cardiovascular: well perfused, pulses equal in all extremities, unable appreciate heart sounds over oscillator Chest: comfortable on HFOV, no retractions Abdomen: patent anus, no hepatosplenomegaly or masses, soft, active bowel sounds, umbilical lines in place Genitalia: normal for age Extremities: well perfused, no deformities Neuro: age appropriate tone, moves all extremities spontaneously, primitive reflexes (more, suck, grasp) normal Skin: brisk capillary refill, no rashes what are the correct CPT code Do not put diagnosis codes

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