History and Physical Examination of the Newborn

Our history should: a)Identify diseases that can be remedied with preventive action or treatment b)Anticipated conditions that are of clinical importance (eq. gonococcal conjunctivitis) c)Uncover possible causative factors that may explain pathologic findings (eq. rubella syndrome babies)

1.WHERE AND WHEN DO WE GET THE NEONATAL HISTORY? 2.WHO ARE OUR INFORMANTS? 3.WHAT ARE THE QUESTIONS WE NEED TO ASK? 4.WHY ARE WE ASKING THESE QUESTIONS? 5.HOW ARE WE GOING TO WRITE OR PRESENT OUR HISTORY?

WHERE AND WHEN DO WE GET THE NEONATAL HISTORY? a)On admission of the pregnant woman to the labor room b)During labor in the labor room c)During the delivery in the delivery room or operating room d)After birth in the mother’s room

WHO ARE OUR INFORMANTS? a)The mother b)The father c)The OB resident d)The OB consultant e)The anaesthesiologist

General Data of the Infant: Birth weight, gestational age, intrauterine growth (AGA, SGA, LGA), type of delivery, race, sex, date and time of birth.

General Data of the Infant: Baby Boy Vasquez, Filipino, born by normal spontaneous delivery with a birth weight of 3010 grams, appropriate for gestational age, 38 6/7 weeks age of gestation at 3:10 AM on June 23, 2009

Obstetric and Maternal History: Obstetric and Maternal History: Age; marital status, Gravida, Para ; blood type, VDRL/RPR (date and results), race, EDC. Previous complications of pregnancy, labor, delivery. Type of contraception used, if any. Was present pregnancy planned? Any pre-existing medical condition, drug use, alcohol intake and cigarette smoking, etc.

OB and Maternal History The mother is a 35 year old Filipina G3 P2 (2002), Blood type O+. Expected date of Confinement: July 2, G Full term baby boy delivered by normal spontaneous delivery Birth weight= 3020g. Stayed in the nursery for 3 additional days for jaundice secondary to ABO Incompatibility. No other complications G Full term baby girl delivered by normal spontaneous delivery Birth weight= 2750 g Uncomplicated stay in the nursery. G Present pregnancy The mother has no history of pre-existing diseases and denies drug use, alcohol intake and cigarette smoking.

History of Present Pregnancy: Location of prenatal care and number of visits. Complications of pregnancy: Special test, ultrasound exams, stress tests. Medications - drug, dose, route, length of therapy, indication, when used during pregnancy. Any infection during pregnancy and medications taken

History of Present Pregnancy The mother has regular monthly prenatal check up since 2 months age of gestation and every two weeks from 37 weeks age of gestation. Vaginal bleeding occurred during the second month of pregnancy and the patient was given Isoxsuprine 10 mg tab every 8 hours for 5 days. There was no recurrence of the vaginal bleeding. Serial ultrasounds done during the prenatal visits were all normal. The mother had urinary tract infection on the 4 th month of pregnancy and she was given Cefuroxime 500 mg tab, one tablet twice a day for 7 days. Urinalysis on admission is normal.

Course of Labor and Delivery: Labor spontaneous or induced? Complications of labor Fetal monitoring? Fetal distress? Rupture of membranes: artificial or spontaneous, hours before delivery, character of fluid. Medications - including analgesia and anesthesia: drug, dose, route, time prior to delivery Duration - Stage I, Stage II, Stage III Vaginal - or C-section delivery Fetal presentation and position Forceps used? If so, state type and indication Apgars 1 min / 5 min (Specify points lost at each) Resuscitation: none; bulb suction; free flowing oxygen; bag and mask; intubation, drugs used (dose and route)

Course of the Labor and Delivery The mother had spontaneous labor 3 hours prior to admission. The course of the labor was unremarkable. Regular fetal monitoring showed no abnormal fetal heart rate decelerations. The membranes were artificially ruptured at 6 cm cervical dilatation showing normal amount of non foul-smelling whitish amniotic fluid without meconium staining. The duration of the stages of labor are within normal limits. The baby was delivered by normal spontaneous vaginal delivery on the 16 th hour of admission under epidural anesthesia. Routine resuscitation was done and the APGAR scores were: 1 minute APGAR : 9 ( minus 1 for color) 5 minute APGAR : 10

Course in the Transitional Nursery:  VS on admission (including BP and temperature)  Hematocrit  Dextrostic  Problems: cyanosis, respiratory distress, etc.  Estimate of gestational age by Dubowitz - physical score, neuromuscular score

Family History: Relationship of neonate's mother and father (married, divorced, cohabiting, live apart, no contact maintained, etc.) Mother: amount of education, and is she employed outside of the home? Father: age, amount of education, occupation Any illnesses or other problems in household members? Any significant illnesses (physical, mental, growth failure) in other members of father's or mother's family? If so, what? Is there any disorder(s) in particular that mother worries her child might develop?

Family History The mother and father are presently not married but are living together alone in a rented apartment. The mother is a high school graduate presently working as a sales staff in SM megamall while the father is a college graduate working as a manager in a call center. There are no heredofamilial diseases in both sides of the family. They presently reside in a rented two bedroom apartment win Taguig with potable water supplied by Manila Water. The two other children share one bedroom. The parents plan to put the baby in a crib next to their bed in the Master bedroom. Presently, their income can support their household expenses

A.Stakeholder – person(s) other than the patient who have an impact (or interest) on the changes that need to happen to improve patient’s health. B.Interest in Issue C.Role – position with regard to the required changes: whether ally, resistor or bystander. D.Level of influence STAKEHOLDER ANALYSIS

PERTINENT BELIEFS PERTINENT BELIEFS – underlying belief systems that have an impact on how the patient thinks, feels, and behaves about health; ex. Jehovah’s Witness and blood transfusion, or beliefs about bodily integrity in death and possible limb amputation, etc. IMPACT ON FAMILY IMPACT ON FAMILY – psychological, social, economic impact of the patient’s disease on the family as a unit, and on its individual members.

COMMUNITY FACTORS A.Facilitating – factors that would help the patient achieve/restore/maintain health B.Hindering – factors that would hinder the patient from achieving/restoring/maintaining health C.Burden of illness – review of data regarding the burden of the patient’s particular illness in the community / country / region / world D.Pertinent Legislation / Policies – review of any pertinent legislation or policies that would have an impact on the care of patients with their particular condition

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