History taking in neonatology

Importance of history taking

• Basis of diagnosis
• Examination
• Laboratory –support,confirm,assess progress
 Antenatal

• VDRL
• Blood group
• Urinalysis.OGTT
• HIV screening
• Infections UTI, PV discharge,Fever,
• PIH,PET
• Drugs
• Radiation
• Alcohol use,nicotine
 Obstetric History
• Parity
• Menarche,cycles
• Use of contraceptives
• Past pregnancy-gestation,mode of
delivery,wt,
neonatal morbidity, alive or
dead
 Past medical history
• Diabetes
• Hypertension
• Epilepsy
• Asthma
 Family/Social
• SES
• Diabetes
• Hypertension
• Age both parents
 Birth history

• Gestation
• Labour ? Spontaneous , duration ,fever
• Rapture of membranes , Liquour,
• Presentation
• Mode of delivery and indication if assisted/CS
• Apgar score,wt
 Potential for sepsis
• Maternal infection,fever
• PROM
• Prolonged labour
• Chorioamnionitis
Progression
 Physical examination
• Gestation and age assessment
• Neonatal reflexes