DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
ADMISSION DIAGNOSES:
1. Esophageal reflux.
2. Failure to thrive.
FINAL DIAGNOSIS: Gastroesophageal reflux.
SECONDARY DIAGNOSIS: Status post prematurity, 36 weeks.
LABORATORY DATA: Hemoglobin 12.2; white count 11,200; 3 segs, 1 band, 85 lymphs, 6 monos, 5 eos; 432,000 platelets. Cath urine: Specific gravity 1.010, pH 7. Dip was negative. Sodium 139, potassium 5.8, chloride 108, CO2 of 24, glucose 72. AST 36, ALT 18, alkaline phosphatase 222, and bilirubin 0.6. Urine with no growth.
Esophagogram showed no evidence of duodenal obstruction or pyloric outlet obstruction but cardioesophageal reflux. Chest x-ray showed minimal infiltrate in the right lower lobe.
HOSPITAL COURSE: This baby did quite well when fed by nurses and was treated with reflux precautions. He was continued on his Zantac from prior to admission, and the hospitalization was basically spent in both documenting the reflux and the lack of another etiology for his failure to grow and also in teaching mother, father, and maternal grandfather techniques of feeding and avoiding reflux problems with a somewhat tricky baby to feed, requiring a fair amount of stimulation, but he actually did quite well with reflux precautions.
The mother herself was sick and was absent from the baby’s room for 36 hours, and so father and grandfather fed the baby well during that period of time. There were no apneas or bradycardias with only occasional loose lead alarms on his apnea monitor.
It was our clinical impression that the entire apnea problem was probably related to reflux from the beginning. By the morning of date of discharge, the baby was tolerating 3 ounces of LactoFree every 3 hours with no vomiting, and mother was feeding him well. The entire family demonstrated comfort in reflux precautions and in administering the Zantac. He was discharged home to be seen in the office in 3 days.
