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NICU-Progress NoteVitals: Temperature: 98.4°F Pulse: 160 Respirations: 40 Blood Pressure: 60/28 Physical Examination General: no distress, resting in isolette, asleep, responsive and pink HEENT: anterior fontanel open, soft and flat and mucous membranes clear and moist Cardiovascular: rrr, no murmur, well perfused Chest: clear breath sounds bilaterally Abdomen: soft, active bowel sounds Neuro: age appropriate tone, moves all extremities Skin: brisk capillary refill, plethoric Impression: Gestational age, 29 weeks Liveborn infant of single pregnancy, born in hospital by cesarean delivery RDS, slowly resolving. Plan: FEN: This is my first observation of baby Sioban, who needs intensive monitoring while the RDS is still resolving. Await regular weight gain. On full volume feeds around 160 ml/kg/day using EBM or donor EBM fortified to 24 cal/oz with HMF. On MVI. Ok to go to the pumped breast ad lib. Metabolism: Newborn screen needs repeated for CAH (mildly abnormal and amino acid panel). Respiratory: RDS resolving. Room air. Monitor events. Remains on Caffeine. Heme: Keep HGB greater than 10. Will get supplemental iron at 2 weeks of age. ROP: This baby qualifies for retinopathy of prematurity screening at 5 weeks of age. DISCHARGE PLANNING: Anticipate readiness for discharge to home when all PO feeds, showing acceptable pattern of weight change, maintaining temperature in an open crib and clinically stable. The baby will need to be given a Hepatitis B vaccine and pass an ABR prior to discharge. CHO screening need. PCP identified as Dr. Denny. Need a carseat study prior to discharge. what are the correct CPT codes Do not put diagnosis codes
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