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PATIENT’ S BIODATA
SEX: female
WARD: N.I.C.U
I.P.NO: 10110338
DATE OF ADMISSION:7/12/10
INCOME: 5,000/-Rs
CHIEF COMPLAINTS:
Baby not cried immediately after birth. She is having apnea at birth and non vigorous
aspiration of meconium stain liquor. Apgar score is 8/9. Resuscitation per positive pressure
ventilation for 2 minutes and transferred to nursery under free oxygen per face mask.
Admitted to nursery with special care nursery orders, medical diagnosis RDS and non
vigorous mecomium aspiration ; weight is 2.130 kg. Mother is 23 years old, primi gravid
and experiencing complicated delivery requiring admission to surgical unit STAT.
baby not cried immediately after birth. She has respiratory distress after birth
BIRTH HISTORY:
ANTENATAL: Mrs. Induben makawana had regular antenatal visit , also gain weight, no any
problem encountered, immunization 2 T.T injection taken.
INTRANATAL: Delivery was vaginal. Birth weight is 2.310 kg. baby not cried immediately
after birth. Apgar score is 8 at birth, after 5 min 9.
FAMILY HISTORY
FAMILY TREE:
Patient
Male
Female
FAMILY HISTORY OF ILLNESS: no other family members have no any major diseases
like tuberculosis, ischemic heart diseases ,cancer ,asthma ,allergy ,etc.
PHYSICAL EXAMINATION:
1.General health –
Weight : 2.310 kg
Height : 48 cm
Head circumference : 32 cm
Posture : body flexed, hands tightly clenched,neck appear short because cheek rest on chest.
2 . Skin – color and sign of jaundice is to be noted. dehydration is present. milia is present
across the bridge of nose.
3. Head : round , symmetry ,easily move left to right and down to up, greater than chest
circumference. Anterior fontanel is 4-5 cm in diamond shape. 1-2 cm at birth triangle shape.
slight pulsation and bulging is also present. Hair is smooth with fine texture. Hair distribution is
also normal.
4. Face : symmetric movement of all facial features. Eyebrows and eye lashes present. Eye-ear
at same level. Nostrils equal size.Facial skin – Smooth pink.
5. Ears – pinna is parallel to the outer and inner can thus of eyes. Both ear is symmetric.
Responds to voice and sound
6. Eyes – Bruised and puffy eyelids. Blinking to be observed. Focusing on the line of vision to
be noted.
7. Nose – Shape. Breathing normally through both nostrils with lips closed. Sneezing is noted.
8. Mouth – hard palate in domed shape. Uvulva midline with symmetric movement of soft
palate. Tongue freely moving in all direction.
9. Neck – short , straight, creased with skin folds. Contraction of the shoulder and arm muscles
11. Chest – 2 nipples symmetric.breast tissue diameter is normal like 5 cm in diameter. Breast
may have some enlargement. Symmetrical expansion of chest. transient breath sound is heard
because of secretion present in respiratory track. Sometimes brief apnea is present . heart sound
auscultate normal rate and rhythm without murmur.
12. Abdomen: cylindrical with some protrusion. Appears large in relation to pelvis. No
protrison of umbilicus . two arteries and one vein is present.
13. Genitalia –Female – clitoris is covered with labia majora . Normal skin color. No vaginal
tag. Vaginal discharge is not present. Buttocks are symmetric. Me conium pass 4 hrs after
birth.
14. extremities and trunk- short and generally flexed, extremities moves symmetrically through
range of motion but lack of extention. Arms and legs also equal in length. Palmer crease is also
present. Legs shorter than arms. C- shaped spine.
16. Urine passing –12 hours after birth. One wet diaper every 8 hours on day 2. This will
gradually increase to 6-8 wet diapers in 24 hours on day 5.
18. Reflexes- Moro’s, Routine, sucking ,palmer grasp, babinski reflex is present
12. INVESTIGATION
Renal function
test
Blood urea 38 mg/dl 15-45mg/dl Normal
Serum creatinine 0.88 mg/dl 0.7-15 mg/dl Normal
Liver function test
Billirubin total 0.8 0.2-1.2 Normal
direct - 0.0-0.5 -
indirect - 0.0-0.2 -
Serum alkaline 184 <500 less
phosphate
S.G.P.T 39U/L 0-55U/L Normal
Prothrombin time 13sec 9.5-14.1 sec Normal
INR 1.13Sec - -
C-Reactive 2.4mg/dl <0.6mg/dl Positive
protein
OTHER INVESTIGATION: