Transcript Our history should

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)
b)
c)
d)
e)
The mother
The father
The OB resident
The OB consultant
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:
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, 2009.
G1 2002 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
G2 2004 Full term baby girl delivered by normal
spontaneous delivery Birth weight= 2750 g
Uncomplicated stay in the nursery.
G3 2008 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 4th 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:
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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 16th 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:
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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
STAKEHOLDER ANALYSIS
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
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 – 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
THANK YOU