This document summarizes the medical history and examination of a 4-day-old female neonate admitted with low birth weight and jaundice. She was born preterm at 32-34 weeks gestation to a 22-year-old mother with anemia during pregnancy. On examination, she displayed physiological jaundice but was otherwise healthy, with normal vital signs, growth parameters appropriate for gestational age, and no abnormalities found on physical or neurological assessment. She was assessed as being a preterm neonate with jaundice likely due to physiological causes related to her prematurity.

2.  B/O Jaya 4 days old female neonate
 1st born of non consanguinous parents
 Informant –mother ,reliability –good
 Date of birth-22.1.18 at 5.15 a.m
 Date of examination – 25.1.18
 Admitted on day 1 for low birth weight care
and found to have yellowish discolouration
since day 2 of life

3.  h/o yellowish discoluration since day 2 of life
initially noted in eyes
progressively seen in abdomen and thighs
 No h/o fever or hypothermia
 No h/o lethargy, irritability, poor feeding,
seizures.
 No h/o swelling over scalp
 No h/o any bleeding manifestations
 No h/o birth injuries
 No h/o abdominal distension

4.  No h/o high coloured urine

5.  Age at menarche – 15 yrs
 No h/o irregular menstrual cycles
 Age at marriage-21 yrs
 Conceived soon after marriage.
 Pregnancy detected by UPT at 40 days of
amenorrhea , confirmed by USG at 2 months
 Registered at nearby phc at 2 months
 LMP-not known EDD- not known
 Prepregnancy weight-39kg, ht-140 cms

6.  h/o hyperemesis gravidarum
 No h/o fever / rash / post auricular swelling
 No h/o drug intake, radiation exposure
 No h/o bleeding pv
 Not taken folic acid tablets
 Usg done at 2 month, said to be normal

7.  Quickenning felt at 5th month. Able to
percieve fetal movements thereafter
Not taken oral supplements regularly
 h/o 1 dose of iron sucrose infusions was
given
 No h/o bleeding pv
 No h/o PIH/GDM, hypothyroid complicating
pregnancy or any other medical illness.
 Inj TT 2 doses given at 5th and 7th month
 usg done at 5th month,said to be normal

8.  NO h/o PIH/GDM/UTI
 h/o anemia (Hb8 gms) for which 4 doses of
iron sucrose injections were given
 Continued to perceive fetal movements well
 USG done at 7th month. Said to be normal.
 At 8th month of gestation, mother had lower
abdominal pain and admitted on 21.1.18 in
RMMCH said to have labour pain.
 No h/o premature rupture of membranes
 One dose of IM injection was given before
delivery.

9. Delivered a female baby of weight 1.7 kg by
normal vaginal delivery on 22.1.18 at 5.15
am. Cephalic presentation. Cried immediately
after birth. Clear liquor, not foul smelling.
routine care was given.
No h/o birth asphyxia, respiratory distress,
Cyanosis, obvious congenital anomalies at
birth.
Admitted in nicu for preterm, low birth weight
care.

10.  Started on EBM on day 1 of life and direct
feeds since day 3 of life
 Urine and meconium passed on day 1.
 No h/o seizures, respiratory distress,
cyanosis.
 No h/o jaundice on day 1

11.  Non consanguinous parents
 Mother 22 yrs, house wife, blood group A
positive
 Father 32yrs, working as driver, blood group
not known
 No h/o preterm delivery in family
 No h/o jaundice , anemia in family
 No h/o surgeries among family members

12.  Thatched house
 4 members in family
 Use gas stove for cooking
 Use bore water for drinking
 Toilet facility available
 Monthly income rs :15000
 Lower middle class

13. 4 days old preterm female neonate(32-34
wks) born to non consanguinous parents,
primi high risk mother with anemia with no
intrapartum complications with low birth
weight and neonatal hyperbilirubinemia.

14.  Cry & activity –good
 Colour- Icterus upto thighs
 Krammer’s index – 12mg/dl
 Posture-arms slightly flexed, legs flexed
&abducted
 Breathing- abdominothoracic
 Iv cannula in lt hand

15.  normothermic
 All peripheral pulses felt equally on both
sides.
 HR-130/min, regular.
 RR-48/min
 CRT <2sec
 Spo2-96% in room air

16.  Weight -1.7 Kg, AGA, between 50th and 90th
percentile.
 Length - 43cms, 50th percentile.
 Head circumference-30.5cms, between 10th
and 50th percentile
 Chest circumference-21cms
 Abd girth 25cms

17. SKIN
 smooth, visible Veins
 Abundant lanugo hairs
 Icterus upto thighs
 no pallor/cyanosis / mottling
HEAD&SKULL
 scalp hair fussy
 AF –open 1*1 cm flat, PF- admits tip of the little
finger
 No cephalhematoma, cranio tabes
 sutures normal
EYES: open, icterus +, no discharge, no hypertelorism
NOSE: normal

18. ORAL CAVITY :normal.
EARS-Slightly curved pinna, soft , slow recoil
NECK :Normal
Chest-breast bud, 1-2mm, areola stippled,
nipple flushed with surface.
Abdomen- no distension , umbilical cord
healthy
BACK –normal
Genitalia - enlarged clitoris, labia minora
equally prominent
Anus - patent

19. Lower limb normal, faint red marks seen on plantar
surface.
Hip- Ortolani, Barlow negative
Neuromuscular maturity tests:
Heel to ear-140 degree
Popliteal angle-140 degree
Scarf sign-elbow crosses the midline
Square window – 30 degree
Gestational age assessment:
Physical maturity- 8
Neuromuscular maturity - 14
New ballord score – 22 (32-34 weeks)

20.  CVS
Apex not seen.
Apex felt at left 4th ICS, lateral to mid
clavicular line
s1,s2 heard. No murmur
Pulses well felt in all vessels on both sides
 RS- B/L chest movement equal,
B/l air entry equal
No added sounds

21.  Abdomen –
soft
no distension
liver felt 2cm below the right costal margin
liver span 5.5 cm
umbilical cord - healthy

22.  Cry good
 Spontaneous eye opening +
 Upper limb flexed at elbow, lower limbs
semiflexed at both hip and knee
 No abnormal postures

23. Blinks on showing light, B/L Pupils equally
reacting to light, not follows light
Dolls eye movement(+)
Rooting (+)
Sucking fair
No facial asymmetry
Good cry volume, swallowing(+)

24. 180 degree flip test:
pull to sit-head lag(+),rounded back
Axillary suspension- does not slip from hands,
mild flexion at hip and knee
Ventral suspension- all 4 limbs extended ,neck
flexed
 Power > 3/5 in all 4 limbs

25.  Rooting present
 Sucking fair
 Grasp reflex present
 Stepping, placing present
 ATNR(+)
 Moro reflex present, incomplete.
 Galant reflex+

26. 4 days old LBW PRETERM (32-34weeks), female
neonate, Appropriate for gestational age,
admitted for preterm care and neonatal
hyperbilirubinemia probably physiological
hyperbilirubinemia without complications

27.  THANK YOU