This document contains a template for documenting personal and medical history for a newborn baby. It includes sections for personal details, presenting complaints, obstetric history organized by trimester of pregnancy, natal history, postnatal history, immunization history, family history, socioeconomic history, physical exam findings organized by system, assessment of gestational age, anthropometry measurements, and neurological exam including reflexes. The physical exam section provides details to assess for any dysmorphisms or abnormalities.

1. BINISHA SEBBY
ROLL NO :21

2. PERSONAL
DETAILS
 Name – baby of __
 DOB – if less than 72 hrs,
time of birth mentioned.
 Age – in days (if < 72 hrs , in
hrs).
 SEX-
 Address:
 Gestational age at birth (as
per LMP)
 EDD- Especially for preterm
 Weight (AGA/SGA/LGA):
 Maternal age:
 GPLA
PRESENTING
COMPLAINT
• Icterus
• Feeding difficulty
• Seizures
• Bowel /Bladder problems
• Looking sick
2

3. I TRIMESTER
 Maternal age at conception
 Registered pregnancy/not
 Detection of pregnancy
 Conception
 USG –Dating scan
 Nausea/vomiting
 Hyperemesis gravidarum
 UTI
 Folic acid
 Bleeding profusely
 Infection
 Radiation
 Drug intake
II TRIMESTER
• USG –Anomaly scan
• Quickening
• TT – first dose
• Iron
• Calcium
• Folic acid
• GDM
• PIH
• Bleeding PV
• Oligamnios/Polyhydramnios
3
III TRIMESTER
 USG-Growth scan
 TT –second dose
 Iron
 Calcium
 Folic acid
 Bleeding PV,UTI
 Oligo/Polyhydramnios
 Anaemia
 Smoking
 Decreased fetal movements
 Weight gain :10-12kg
Mothers obstetric and medical history if relevant

4. NATAL HISTORY
 Term/preterm
 Place of delivery- home/
hospital
 Normal vaginal delivery/
LSCS(indication)
 Presentation of baby- vertex
/breech
 Onset of labour
 Duration of labour
 H/O complications like
uterine rupture,maternal
fever,foul smelling liquor
 Weight of the baby at birth
POSTNATAL HISTORY
• Cry
• Breast feeding-
duration,frequency,adequacy
• H/o any bottle feed
• Meconium
• Micturition
• H/o jaundice,respiratory
distress,seizures
• NICU Admission
4

5. IMMUNIZATION
HISTORY
 BCG
 Polio
 Hepatitis B
FAMILY HISTORY
 Any hereditary/major illness
 Recurrent blood transfusions
 TB
 Neonatal deaths
 Developmental delays
5
SOCIOECONOMIC
HISTORY
 Modified Kuppuswamy
scale
 House
 Bathroom
 Overcrowding

6. IMMEDIATELY AFTER BIRTH:
 Weight
 Gestational age
 Congenital anomalies
 Sex assigning
 Examination of umbilical vessels
and placenta
 APGAR SCORES-(done at 1
minute and 5 minute after birth)
• POSTURE AND ACTIVITY: term baby has universal flexion.
• GENERAL BEHAVIOUR
• OVERALL APPEARANCE: Well /sicklooking,alert /unconscious
• GENERAL SURVEY: Pallor,icterus,cyanosis,edema,Lymphadenopathy and clubbing absent.

7. VITALS
 Colour of the child-
 Temp:NORMAL-36.5-37.5°C ,
36-36.5°C – Cold stress
<36°C- Hypothermia
Site- anterior abdominal wall &compare with
extremities
 RR: 40-60/min, Abdominothoracic
 HR: 120-140/min
 CFT: ≥3 sec -Abnormal
 BP: 60/40 mmHg(PRETERM BABIES ,still lower) 7
• Term baby-pale pink
• Extreme premature baby- very red
• Peripheral cyanosis – Normal, disappear by
warming /clothing
• Central- cyanotic heart disease, Resp distress
• Localized-local pressure during delivery
• Icterus-forehead,sternum,abdominal
wall,thighs,leg and sole

8. 8
GESTATIONALAGE ASSESSMENT:
Physical and neuorological criteria must be scored and plotted to find the exact
gestational age. Expanded Ballard Score/ Dubowitz Scoring.
SIGNS TERM BABY PRETERM BABY
1. Sole creases Many deep creases. Absent/single deep crease anteriorly.
2. Male genitalia Scrotum pigmented with multiple
rugae.testis-descended.
Scrotum small,less pigmented,pink,few
rugae,undescended testis.
3. Female. Labia majora covers labia minora and
clitoris.
Labia majora widely separated.
4. Ear cartilage Well formed,ear folds also.recoils
instantly when the ear is folded.
Thin,folds not well formed,does not recoil
instantly.
5. Breast nodule 5-10mm palpable nodule. <5 mm, not palpable nodule.
6. Tone Limbs are well flexed.tone is good. Limbs are lax.hypotonia
7. Skin Pale and thick. Very red,thin,transparent,veins visible.
8. Hair Scalp-black and silky,lanugo absent. Scalp-less black,thin,lanugo seen over the
body.
BY
PHYSICAL
CRITERIA

9. 9

10. Based on Gestational age, irrespective of the birth weight,
• Preterm – A Neonate born before 37 weeks.
• Term –A Neonate born after completed 37 weeks and before 42 weeks
• Post-term - A Neonate born after 42 weeks.
According to birth weight ,irrespective of gestational age ,
• LBW neonate –birth weight less than 2.5 kg
• VLBW neonate – birth weight less than 1.5kg
• ELBW neonate- birth weight less than 1 kg.
Based on weight for gestational age,
• AGA – birth weight ,10th-90th centile for that gestational age
• SGA-below 10th centile
• LGA – above 90th centile

11. ANTHROPOMETRY:
• Weight- 2.5-3kg( By electronic weighing scale)
• Length 47-50cm (By infantometer)
• HC - 33-35 cm
• CC - measured at the level of nipples
CC is 3cm < HC at birth.
• Ponderal index = Weight (gm)
(Length)³(in cm³)
X 100

12. HEADTOFOOTEXAMINATION:
 Dysmorphism
 Skull- AF,PF,Caput succedaneum,cephal hematoma
 Face- Any Dysmorphism
 Eyes- Discharge,Microphthalmia,Slant eyes ,Icterus,look for red reflex
 Ear- Low set ears, Preauricular tags and pits
 Mouth- Sucking pad- localized thickening of mid upper lip.
- Cleft lip/ palate,look for oral thrush
- Protruding tongue-seen in Down’s syndrome,hypothyroidism
- EPSTEIN PEARLS- Retention cysts located in the midline near the junction of
soft and hard palate.
 Nose- DNS, depressed nasal bridge
 Neck- webbing of neck in Turner’s syndrome,palpate thyroid and clavicle ,fistulous
openings.

13.  Chest- Shape of chest, nipple position /spacing
 Umbilical cord- Shriveled, Foul smelling, Erythema around umbilicus,Bleeding
 Genitalia- Undescended testis, Hydrocele,Hernia,Poorly pigmented scrotum,Exposed
labia minora.
 Anal opening- Imperforate anus
 Arms and legs-Erb’s palsy, Oedema of the hands and feet in Turner’s syndrome,
Proportions, No.of fingers, Palmar creases, Club foot.
 Back and spine- Meningomyelocele, Sinuses, Sacral pits
 Hip- Congenital dislocation
 Skin- Colour of the skin, Pallor, Plethora, Mottling, Jaundice
Salmon patch (Reddish macules over lids and nape of neck)
Mongolian spots –Grayish blue spots in the lumbosacral area

14. SYSTEMIC EXAMINATION:
NEUROLOGIC EXAMINATION: Done beyond 24 hrs of postnatal age.
 Assess gestational age,behavioural state of alertness,any sickness ,drugs,posture
 Observe feeding on breast (check positioning and attachment)
 HIGHER FUNCTIONS:
Mental state of wakefulness,irritability,consolability,cuddlability
 Cranial nerve examination:
o 1-Mother’s milk(newborn turns towards breast by smell)
o 2-Fixing at soft light(light from window of a dark room)
o 3,4,6- Eye movements- spontaneous- elicited by doll’s eye manoeuvre.
Procedure- pick up the baby and gently rock backwards,forwards
and from side to side ,observing the eye movements.Tonic deviation to one side could
mean seizure.

15. o 5- Rooting reflex (Child turns with snout towards the side where the corner
of mouth is touched)
o 7- Observe the child cry. Trauma of forceps delivery-M/C cause of LMN facial palsy in
the newborn.
o 8- Behavioural response to sound (Startle, Blinking, Change in HR )
Bilirubin encephalopathy and IU infections cause Deafness
o 9,10- Position of uvula during crying, Choking during feeding
o 11-Lift the head off the bed by holding at wrists and watch for sternomastoids.
o 9,10,12- Sucking and Swallowing.

16. 16
MOTOR SYSTEM:
 Observe spontaneous movement.
 Tone- Passive and Active, Posture at rest, Various angles.
 Caudo-rostral progression- 32 weeks-lower limb tone increases,
Flexion at hip and knee
36 weeks- elbow flexion appears.
 Neck – “pull to sit”
 Trunk -Ventral suspension
REFLEXES: Knee,ankle,biceps

17. 17
NEONATAL
REFLEXES

18. 18
gg
• Opening of hands( 28 weeks)
• Extension and abduction of upper
extremities(32 wks)
• Anterior flexion and adduction of
upper extremities( by 37 wks)
• Audible cry.
Disappears by : 3-4 months

19. Depressed/
Absent
Moro
Generalized depression
of CNS
B/L
exaggerated
moro
Kernicterus
U/L absent
moro
Fracture of clavicle
Fracture of humerus
Erbs palsy
19

20. 20
hhhh
Stroke the ulnar aspect of palm
Appears by 28 weeks
Disappears by 2-3 months
Retention >6 months –athetoid CP

21. 21
Press with thumb on sole
Toes will plantar flex
Disappears by the time baby
starts standing

22. 22
Present at birth
Persists upto 4month (awake)
6 month(asleep)

23. 23
Elicited by touching corner of
mouth with finger
Baby turns towards it to latch

24. 24
Holding baby under axilla & leaning
forward,Place sole on table
Baby makes walking movemnts

25. 25
Hold baby,rub dorsum of foot
on edge of table
Baby lifts and places leg on top
of table

26. 26
hhhj
Ventral suspension of baby
Running down paravertebral area on one side
Swinging of pelvis towards that side

27. 27
hhhj
One leg held in extension & sole rubbed
Other leg first withdraws,
extends with fanning of toes

28. 28
Bba
Baby in ventral suspension
Head is flexed
Hip,knee & elbow flexes

29. 29
Rotate the head
Extension of upper extremity on side
to which rotated
Flexion on side of occiput

30. 30
Extend the neck
Upper limb extends
Lower limb flexes
Used for rise in arm
On flexing neck,the opposite

31. 31
Appears only by 6-9 months
Persists throughout life
Child in ventral suspension,suddenly lower him
Arms extend as to protect

32. RESPIRATORYSYSTEM:
 Shape of chest- Barrel shaped chest +distress  Meconium aspiration syndrome.
 RR ,Retractions,air entry,adventitious sounds.
CVS:
 Pulse volume, Precordial pulsations, Apical impulse, Heart sounds, Murmur.
ABDOMEN:
 Look for distension/scaphoid abdomen(in congenital diaphragmatic hernia)
 Abd.wall oedema, Any tenderness,
 Palpable Liver/Spleen /Kidney, other lump palpable,ascites,hernia sites,Gonads,
Genitalia.

33. 33