This document summarizes the medical history and examination of a 12-day-old male infant born prematurely at 31 weeks gestation. The mother had an unremarkable pregnancy with no complications until abdominal pain at 8 months gestation. The infant was delivered vaginally and admitted to the NICU for respiratory distress and preterm care, requiring oxygen for 7 days. On examination at 12 days of age, the infant's vital signs and growth parameters were appropriate for gestational age. Systemic examination was normal. The diagnosis was a 12-day-old low birth weight preterm infant, appropriate for gestational age, under care for prematurity.

1. Moderator:Prof. Dr. C.S.Balachandran
Presentor:Dr A.Baby praveena

2.  B/O Aishwariya, male baby
 Age 13/365
 Informant –mother ,reliability –good
 DOB-2.11.16 at 8 a.m
 Age at examination 12 days

3. ANTENATAL HISTORY
 Age at marriage-19
 Primi
 Age at conception-20
 Conceived naturally.
 Pregnancy detected by UPT at 60 days confirmed by
USG at 3 months
 5 antenatal checkups,3 USG done

4. 1ST TRIMESTER
 H/O fever ,no rash or post auricular swelling setteled
in 2 days
 No h/o drug intake,bleeding pv,radition exposure.
 h/o hyperemeis gravidarum
 Dating scan done at 3 months

5. 2nd TRIMESTER
 Taken iron and folicacid tablets
 Quickenning felt at 5months
 No h/o bleeding pv
 No h/o anemia/PIH/GDM complicating pregnancy
 Inj TT given
 Anomaly scan done at 6months

6. 3rd TRIMESTER
 NO h/o PIH/GDM/UTI
 h/o anemia (Hb8grams) for which 4 doses of iron
sucrose injections given
 Inj.TT second dose given
 AT 8 th month mother had abdominal pain was
treated at RMMCH with i.m injection for prolongation
of pregnancy

7.  Mother persistently had abdominal pain admitted in
RMMCH.
 Injection Betamethasone one dose was given
 Membrane were ruptured ,baby delivered after 6 rs of
rupture of membrane

8. NATAL H/O
 EDD 12.01.17 GA-31wks
 Baby delivered by vaginal delivery
 Cried soon after birth
 Birth wt 1.7kg

9. POSTNATAL H/O
 Baby admitted in NICU soon after birth for respiratory
distress,preterm care
 On i.v fluids and oxygen for 7 days
 EBM started on D3
 DBF ON D7
 Urine and meconium passed on D1
 No h/o suggestive of neonatal jaundice/neonatal
sepsis.

10. FAMILY HISTORY
 Non consanguinous parents
 Mother 20 yrs studied upto 8th std
 Father 22yrs studied upto 0 t std
 No /o neonatal deaths/neonatal seizures/ delopmental
delay

11. EXAMINATION
 Cry & activity –good
 Colour-pink
 Posture-arms slightly flexed,legs flexed &abducted
 Breathing- abdomino thoracic

12. VITALS
 Temp-normothemic
 All peripheral pulses felt
 HR-130/min RR-48/min
 CRT <2sec
 Spo2-96%

13. ANTHROPOMETRY
 WT 1.7 Kg-10th centile
 LENGTH 43cms-50th centile
 HC-26cms-50th centile
 CC-22cms
 Abd girth 20cms

14. HEAD TO FOOT EXAMINATION
 Skin- smooth, visible Veins, icterus upto chest,no
pallor/cyanosis /haemangioma /mongolian
spots/mottling
 HEAD&SKULL-scalp hair fussy
 AF –open PF- admits tip of the little finger
 No cephalhematoma,cranio tabes
 Eyes opened, no discharge, no hypertelorism

15.  EARS-Slightly curved pinna soft ,slow recoil
 NOSE,MOUTH NECK Normal
 Chest-breast bud1-2mm, areola stippled, no
retractions
 Abdomen no distension cord healthy
 BACK –normal
 Genitalia normal b/l testis palpable
 Anus normal patent

16.  Both limb normal
 Hip-ortolani,Barlow negative
 Gestational age assessment
 New ballord score
 neuromuscular maturity-10
 physical maturity-8
 Total 18-32wks

17. Systemic examination
 CVS-s1,s2 heard no murmur
 RS- B/L chest movement equal, BAE +no added
sounds
 P/A-soft no distension,umbilical cord healthy
 CNS- b/l PERL not follows light no facial asymmetry,
sucking fair rooting&gag reflex +
 Neonatal reflex-incomplete moro+ palmar,plantar
grasp+ stepping and placing negative

18. DIAGNOSIS
 12 DAYS OLD LBW PRETERM (32 WKS
CGA)/MB/AGA FOR PRETERM CARE

19.  THANK YOU