Newborn Note

入院病摘
Chief complaints
just delivered by the mother at our hospital

present Illness
This baby was born to a years old mother with G P A by NSD / CS.
The reason of C/S was PreC/S or elective C/S or .....
She is a singleton / Twin AB.
The 1' min Apgar score is and 5' min Apgar score is .
The gestation age is + weeks and the birth body weight is gm
( percentile ) ,
The birth body height is cm percentile.
The head circumference cm and chest circumference cm.
This baby is a AGA/ SGA / LGA baby.
The ponderal index is ( percentile ) .
The mother has no underlining disease before pregnancy such as DM, HTN, renal
disease.
The prental ultrasound exmination show no placenta previa or congenital anomaly.
During prengnancy, the mother has no PIH, GDM, Preeclampsia, or eclmapsia.
The perinatal history has no complication of labor and delivery such as PROM, fever ,
leukocytosis, prolonged delivery, umbilical protruding, or placenta abruptio.
The amniotic fluid is clear ; mild turbid ; moderate turbid and servere turbid.
No fetal distress is noted. No nuchal cord was noted.
Special note.
This baby was admitted to ourmother-baby-friendly nursery for further care.

Past history

Mother’s name: NO(病歷號):

EDC / / .
The blood type of father is . Father's age: years old
The blood type of mother is . Mother's age: years old.
The mother's prenatal screen:
HbsAg: - ; HbeAg: - ; VDRL - ; Rubella IgG +/- ; HIV -
Mother's past history :
Hepatitis - ; Syphilis - ; DM - ; HTN - ; TB - ; Renal
disease - ;
GBS screen : + / - or Not-screened.

Prenatal medication:
None ;
Dexamethasone -
Rinderon -
MgSO4 -
Yutopar –

Family history
Sibling: no jaundice history
No fetus death.
No SIDS.

Review of systems

General Observation:

Appearance : normal term, No dysmorphic ; No Down's face,

Activity : active. not hypoactive, no irritable, no lethargic, no comatose

Color : pink, not dusky, cyanotic: peripheral, not central.

Cry : strong, not weak, not high-pitched, not cat cry, not hoarse, not

voiceless

Perfusion : good, □poor, □(CFT_________sec.)

Skin : grossly normal, no petechiae, no ecchymosis, no jaundice, no

rash]

P.E.
T：攝氏 度

P：/min

R：/min

BP：nil ( routine checked for newborn )

Dubowitz score : total score ; estimated GA weeks .

◎I.Head

No Normocephaly,
No caput:
No Cephalhematoma:
Anterior fontanelle : softly normal opend ,
Sutures : normally separated,

◎Eyes : □n.p.

No Ptosis, no swelling, no nevus, no epicanthal fold,

Conjunctiva : no subconjunctival hemorrhage
Sclera : normal
Pupils : normal sized
Others:

◎Ears : Normally set, normal formed,

no preauricular tag, no dimple, no dysplasia,

no hypoplasia, no aplasia, not malformed, not seborrhea, not hairly

◎Nose: normal ; nostrils, no flaring alae nasi,

◎Mouth : normal presented

Philtrum : □normal, Vermilion of lips : no normal, No micrognathia, no macroglossia,

No cleft lip, no cleft palate, normal uvula deviated, no bifide uvula

◎Neck : normal ; no webbing, no torticollis, no low hairline, no mass

◎Chest and Lung :

Abnormalities : no pectus carinatum, no pectus excavatum ;

Chest expansion : good,
Chest retraction : not at suprasternal, or intercostal, orsubcostal
Breath sounds : normal,
No inspiratory stridor,
No grunting

◎Heart :

normal heart sound ; normal splitting ; no thrill, no heave

Rhythm : rregular, No Murmur

◎Abdomen: soft, flat , distended, no scaphoid,

Umbilicus : no meconium, no single artery

Bowel sound : normoactive

◎Genitalia and Anus:

Genitalia: male / female

Anus : normal, not imperforate,

◎Extremities: no deformities,

Movement: symmetrical,
Palm : no Simean crease
nail, without meconium
DDH survery : Ortolani/Barlow test : negative
Allen test normal

◎Neurologic Examinations:

Posture : normal, not flaccid

Reflexes: good moro, good rooting, good sucking, normal plantar grasp,
Muscle tone : Good, not hypotonia, not flaccid, not hypertonia
◎Skin: normal skin , no rash, no jaundice, no petechia,

Mongolian spot : back ; extremity ; buttock

A&P
1. Problem: normal newborn
2. Assessment: term ; late preterm
good activity ; pink no cyanotic . good muscle power.
clean skin ; not meconium stained.
good respiratory status, no retraction .
3. Plan:
Diagnostic: normal newborn
Therapeutic: Prevention early bleeding disease of newborn.
Give Vaccination of HBV or HBsIG
Prevention for conjuntivitis of newborn.
Room in and start breast feeding
Educational: monitor vital sign.
monitor jaundice
monitor body weight change
check newborn screen after 24 hr and feeding.
arrange AABR for hearing.

出院病摘

入出院診斷:

1.normal newborn
normal newborn ; term ; NSD; C/S
male female
Singleton ; Twin AB

主述: just delivered by the mother at our hospital

病史及體檢發現: (入院病摘帶入)

住院治療經過:
This normal newborn was care by the standard of mother-baby-friendly routine. We
started breast feeding soon. Formula milk was not given for this baby for any
medical indication. We monitor the body weight and the bilirubin level. AABR and
newborn screen were done before discharge. This baby was discharge today and will
be followup at our OPD after discharge.

合併症: no pathologic jaundice

出院計畫:

其他指示: Prevention sundden infant death.

Monitor skin color for jaudice progress.

Education for skill for breast feeding
Education the indication and methodology of formula milk use
Prevent drug for G6PD deficiency before the result of screen.
Avoid BCG vaccination before SCID screen result
Education of umbilical care
Mornitor stool pattern and color.

Education use of 兒童健康手冊

OPD FU