Neonatal Case taking
Short description : A --------weeks , --------grams, AGA/SGA/LGA, male/ female
admitted in view of ……………………
Antenatal history:
Maternal age: ht: wt: BMI:
Married life : ……yrs parity : GPALD LMP : EDD:
Conception : spontaneous or with Rx
Booked at what GA…………….
ANC – [Link] check ups
Scans – details, [Link] ,
TT immunization and iron folic acid
Any h/o fever with rashes, joint pains
H/o PIH (after 20 weeks) / chronic HTN (before 20 weeks GA)-
how many drugs? Doses? Since how long?
H/o value of recent BP recording, proteinuria, edema, oliguria, any investigations (LFT,
platelet count)
IUGR – when detected, Dopplers – increased resistence, ADEF, REDF, Redistrbution in
MCA, AFI- , BPP
H/o GDM/ pre GDM/ DM on diet or insulin
Controlled or not, recent values ??, HbA1 values ??
Compliance with Rx
Scans – LGA?, TIFFA , fetal echo ??
H/o Hypothyriodism – when diagnosed?, medication??
Any other medical problems ………….when detected, drugs, ??
Anemia, SLE, jaundice, CHD, heart disease,
H/o – PPROM – duration, uterine tenderness, foul smelling liquor, TLC, HVS (if taken)
H/o – UTI – recent culture (with in one month of delivery is significant)
Any H/o drug intake – NSAIDS, anti depressants etc.
Natal history :
Duration of labour – first stage (> 18 hours sig), second stage (> 2 hours after full dilataion)
Augmentation of labour / induced/ assisted vaginal
Fluids during labour, fever – what antibiotics??
CTG – normal / suspicious/pathological
MSL
LSCS – indication, elective or emergency (specify the reason)
Resuscitaion – yes or no ………IPPV – how long, ET, Medications, chest compressions ??
APGAR -
cord pH , pCO2, BE (Acute – only , pCO2 will be high or chronic insult- , pCO2 and BE are high)
Placenta – weight, surface, [Link] cotyledons, calcifications, malformations, clots etc
Postnatal/ history of present illness
Main reason for admission – elaborate each symptom, problem oriented
• Prematurity :
• Reason (maternal indication or preterm labour or PPROM with chorioamnionitis)-
describe each in detail
• Steroids : What drug ? Dosage? How many doses, duration of last dose from the
time of delivery, how many courses
• Respiratory distress:
H/o – PPROM, UTI , fever during labour – what antibiotics mother is on?
• Onset, progression, course of events
• Silveman / downe’s score
• Respiratory support – CPAP, Ventilation, Oxygen (settings)
• Surfactant - doses,
History for pneumonia, HMD, MAS, TTNB (labour before LSCS, excess fluids during labour)
• IUGR :
• Reason : maternal (PIH, SLE, HTN),
• Placenta
• Dopplers
• AFI
• TIFFA scan
• Jaundice:
• History of onset, progression
• Colour of stools, urine if prolonged jaundice
• Maternal blood group, jaundice in mother
• Family h/o jaundice, phototherapy, exchange, early gall stones, spleenectomy,
blood transfusion
In all cases after elaborating the symptom
Feeding – NPO or when started, how much
Past history: in case of readmission
Family history: no of children ,
Previous Obstetric history:
Socio economic history: education and occupation of mother and father
Kuppuswamy classification
Examination
General disposition: Baby is in level I/II/III/ with mother / placed in incubator or under radiant warmer
Clothed/ semiclothed/ naked
Mention all accessories – temperature probe, pulse oximeter probe (on which limb)
IV cannula, PICC line, UVC, UAC, any medication drips/ infusions, cling wrap/
phototherapy/ CPAP/ Ventilation
Vitals:
• Temperature - of the baby, set temp, heater output, peripheral to core temp difference
• HR - rate, all pulses (esp femorals), volume , rhythm, radio femoral delay
• RR – rate, SpO2 - room air/ oxygen – FiO2
• NIBP – MAP, systole, diastole, pulse pressure, which limb
• CFT –
• Color of the extremities - pink, cyanosed, dusky
General examination – pallor, jaundice, cyanosis, edema
Head to toe examination-
head - size, shape, suture- over riding/ separation
AF/PF/caput/cephalhematoma)
Face – dysmorphism, eyes (cataract/ coloboma), ears, mouth, palate(cleft)
Chest, abdomen, genitilia, limbs,
Spine
If everything is normal – can say as no obvious dysmorphism
Gestational age assessment:
Anthropometry:
Birth weight , length, HC, PI - centiles (Lubchenco chart)
Present weight, lt, OFC (Wt- whether following the postnatal growth curve or not?
ehrankranz)
Ponderal index
Chest circumference – difference with OFC
Mid arm circumference
Systemic examination
Nervous system
• Higher intellectual functions
• Sensorium – normal , stuporous, lethargic, obtunded, comatose
• If normal – state of wakefulness,, state to state variability,
• Habituation – to touch(galbellar tap), sound (crumpling paper), light (on eyes look
for grimace)
• Peak arousablility
• Defence reaction
• Consolabitlity, cudability
• Cranial nerves
• Olfactory(I) –
• Optic (II)– pupillary reflex,
• Oculomotor(III), trochlear(IV), abducens(VI) - movements of eyes – horizontal
(dolls eye), vertical
• Trigeminal(V) , facial(VII) – rooting, sucking
• Auditory (VIII)- response to bell (turning or change in heart rate, breathing pattern)
• Glossopharyngeal(IX) - gag reflex (observe while passing NG tube)
• Vagus(X), hypoglossal (XII)- sucking reflex
• Accessory (XI)- traction reflex
• Motor system
• Passive tone – posture
• Axial – traction (look for head lag), vertical suspension (slipping of the
shoulder – for shoulder tone), ventral suspension (position of head with
relation to trunck)
• Appendicular - upper limb – scarf sign,
lower limb – popliteal angle (asymmetry, difference in angle), adductor angle,
heel to ear
• Flapability -
• Feel of the muscles
• Active tone- arm recoil, leg recoil,
• Reflexes –
• Grasp – palmar, plantar
• Moro’s
• ATNR
• Crossed adductor
• DTR
• Skull and spine
Respiratory system
Mention If baby is on room air/ hood box/CPAP/ ventilator
• Settings – start either from patient’s end or ventilator/CPAP end
• Size of ET tube, fixed at what distance, visible secretions
• Inspiratory or expiratory limb of circuit (condensation), humidifier temperature ,
temperature at patient end
• Settings - mode of ventilation – CPAP/SIMV/PSV
PIP/PEEP/VR/Ti/FiO2/ trigger sensitivity/ termination sensitivity/graphics (if
displayed)
• Spontaneous respirations
• Synchrony of respirations
• Chest rise – inadequate, adequate, more
• RR
• Scoring of respiratory distress if present (Silverman or Downe’s)
• Spo2
• Auscultation – bilateral equal air entry, adventitious sounds( wheeze, stridor, crepitations)
Cardiovascular system
• HR
• Peripheral pulses – rate, volume, femorals, radio femoral delay
• Precordial activity
• Murmurs
• Signs of cardiac failure – hepatomegaly, tachycardia, RD, crepts
Abdomen
• Shape – scaphoid, distended, visible bowel loops
• Palpation – soft/ tense,
• Palpable masses
• Hernia orifice
• Abdominal girth – If grossly distended
Genitalia
