its an undergraduate level case sheet for normal new born without any complications we can alter the history and examination according to findings

1. CASE
PRESENTATION

2. DEMOGRAPHIC DATA
 8 days old female baby of fathima born on 12.07.2018 from
ukadam has been admitted in our hospital for postnatal care
 INFORMANT - mother
 RELIABILITY – good
 LMP : 20.10.2017
 EDD : 27.7.2018

3. ANTENATAL HISTORY
Obstetric score – P2 L2 AO
 1st TRIMESTER
• Spontaneous conception
• Confirmed by urine pregnancy test
• Booked & immunized case
• Dating scan was done and was found to be normal
• No H/O vomiting , headache , fever with rash , burning
micturition , any drug intake , exposure to irradiation
• BP measured and found to be normal

4.  2nd TRIMESTER
• Quickening felt at 4th month
• Immunized with 2 doses of TT at 4th & 5th month
• No H/O blurred vision , headache , epigastric pain , pedal edema ,
burning micturition
• Anomaly scan done and found to be normal
• GCT done and found to be normal
• IFA tablets taken regularly
• BP measured and found to be normal

5.  3rd TRIMESTER
• Weight gain – 10 Kgs
• Normal perception of fetal movements
• No H/O epigastric pain , blurred vision , pedal edema ,
easy fatiguability , breathlessness
• Growth scan done and found to be normal
• BP measured and found to be normal.

6. BIRTH HISTORY
 Full term
 Lower segment caesarian section [ previous LSCS ]
 Baby cried immediately after birth
 Breastfed within 2 hours after birth
 Birth weight – 3 kg
 No H/O birth asphyxia and NICU admission

7. NEONATAL HISTORY
 The child had passed urine & meconium within first 24 hours
after birth
 Fall of umbilical cord was on 6th day
IMMUNIZATION HISTORY
 The child was immunized at birth

8. FEEDING HISTORY
 The child is breastfed 8-10 times a day
 No H/O feed intolerance / posseting
FAMILY HISTORY
 3rd degree consanguinous marriage
 No H/O hereditary diseases running in the family

9. SOCIOECONOMIC HISTORY
 Percapita income – Rs. 2500/-
 Socioeconomic status – CLASS III [according to modified Kuppusamy scale]
ENVIRONMENTAL HISTORY
 Pucca type of house
 WATER SOURCE – corporation water supply
 Sanitary latrines present

10. CONTACT HISTORY
 No H/O contact with tuberculosis / pets

11. GENERAL EXAMINATION
 Posture :
• HIP & ANKLES  partially abducted
• ELBOWS & KNEES  flexed
 Alert – the child is looking all around
 Movements – moves all 4 limbs equally
 Normal cry
 Skin color – normal & no cyanosis / icterus

12. HEAD TO FOOT EXAMINATION
 HEAD
• Anterior fontanelle  flat , 2.5*2.5cm , diamond shaped
• Posterior fontanelle  0.5*0.5cm
• No moulding
• No caput succedaneum / cephalhematoma
• No bruises / cuts / forceps marks on scalp & face
 EYES
• Normal size
• Cornea - clear

14.  EARS
• Normal size & shape
• Recoilability present
• Patent external auditory canal
 NOSE
• Normal size & shape
• Patent nostrils
 MOUTH
• No Epstein pearls seen
• No congenital anomalies
 NECK
• No visible neck swellings
• No webbing of neck

15.  CHEST
• Normal in shape & symmetry
• Nipples – normal in position & number
• No retractions
 ABDOMEN
• Not distended
• No periumbilical redness / bleeding or foul smelling discharge from umbilicus
• No visible peristalsis or pulsations
 EXTERNAL GENITALIA
• Clitoris normal
• Labia majora covers labia minora

16.  BACK
• Spine – normal
• No dimple / tuft of hair / spina bifida
 HIP
• Normal , no congenital dislocation / fixed deformities
 LIMBS
• Arm recoilability – good
• No shortness of limbs & normal digits
 SKIN
• Vernix caseosa – absent
• No color changes
• No Mongolian spots / other neurocutaneous markers.

17. VITALS
 TEMPERATURE – afebrile
 RESPIRATORY RATE – 42 breaths / min
 PULSE RATE – 118 bpm , regular rhythm
 CAPILLARY REFILLING TIME – 2seconds

18. ANTHROPOMETRY
 Weight – 3 kgs
 Head circumference – 34cm
 Chest circumference – 31cm
 Mid upper arm circumference – 10cm

19. SYSTEMIC EXAMINATION
 CARDIOVASCULAR SYSTEM
• S1 S2 heard ; no murmurs
• apical impulse – felt over left 4th intercostal space in midclavicular line
 RESPIRATORY SYSTEM
• Normal vesicular breath sounds
• No added sounds
 ABDOMEN
• Soft , not distended

20.  CENTRAL NERVOUS SYSTEM
• Baby is alert , active
• Good cry
 MOTOR
• movements : normal & moves all 4 limbs equally
• Arm recoilability : normal ; brisk flexion

21. • Pull to sit reflex : head in line with body & then lags
• Scarf sign : doesn't cross midline

22. • Heel to ear test : doesn’t touch ear
 DEEP TENDON REFLEXES : normal

23.  PRIMITIVE REFLEXES
• Moro’s reflex – present
• Palmar grasp – present

24. • Plantar grasp – present
• Asymmetric tonic neck reflex – present

25. • Traction reflex – present
• Rooting reflex – present
• Sucking reflex – present

26. • Stepping reflex – present
• Babinski reflex – present
• Galant’s reflex – present

27. SUMMARY
 A 8 days old term female baby of Mrs. Fathima born
through lower segment caesarian section weighing
3kgs is appropriate for gestational age with no
respiratory distress / seizures