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
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
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