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Discharge SummaryAdmission Data: BG Cassie-Lee Huber was born on 03-27-19 at Gestational Age: 25w3d with a BW of 1 lb 11.9 oz (791 g) to 30 y/o G4P3, by VBAC, Spontaneous secondary to prolonged rupture of membranes, >24 h. Membrane Status: Prolonged, Rupture Rupture Time: 1800 Infant Delivery Summary: Delivery Type: VBAC, Spontaneous Birth Date: 03-27-19 Birth Time: 10:04 pm Gender: Female Birth Weight: 1 lb, 11 oz (791g) Birth Length: 31.8cm Head Circumference: 22cm Apgar 1 Min Total: 7 Apgar 5 Min Total: 8 The infant was admitted to NICU for prematurity, respiratory distress and suspected sepsis: PPROM. Baby: girl at Gestational Age: 25w3d GA. The Newborn admission physical exam was significant for: General: alert in mild resp. distress Skin: Normal- Irregularly shaped erythematous/blanchable 4-5 cm area along the suprapubic area; stable Head & Neck: Mobile sutures, fontanelles normal in size. Eyes: RR deferred Nose: Clear normal mucosa Mouth: palate intact Chest: Retractions Lungs: mild retractions, few crackles, good air exchange. CV: Normal S1 S2, no added sounds or murmurs Abdomen: soft GU: Normal female genitalia, no labial adhesions Ortho: No hip clicks Impression: BG Cassie-Lee is a Gestational Age: 25w3d female. Preterm Appropriate for Gestational Age Female Newborn Admission Diagnosis: RDS Hospital Course: Starter TPN was started shortly after admission, on 03-27-18. Parenteral nutrition was used for 10 days before full feedings were established. Enteral feedings were started on day 11 and advanced to full feeds. The baby was fed breast milk and with Beneprotein for most of her stay, baby progressed to full oral feeds. A day before discharge, she was changed to Ad Lib feeding and tolerated well. Respiratory The newborn’s clinical and radiological course was consistent with Respiratory Distress Syndrome. The newborn required 1 days/months of ventilatory support. The newborn’s respiratory course was complicated by BPD. After extubating, Cassie-Lee required BiPAP for 45 days and CPAP for an additional 4 days, HFNC for 21 days. BG Cassie-Lee also required O2 until discharge and will be going home on home O2. BG Cassie-Lee was treated with caffeine, CPAP and supplemental oxygen. Discharge Disposition: BG Cassie-Lee was discharged to home with feeding bottle feeding on an ad lib schedule. give the correct CPT codes Do not put diagnosis codes

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