2. This is a case of a 3 day old term baby male born to Mrs XYZ residing in
hoskote ,of non consanguineous marriage via normal vaginal delivery
on 23rd April 2020 at MVJ MC & RH .Was brought to the OPD for routine
newborn checkup and care.
3. Demographic Data
• Baby of Mrs XYZ
• Date of birth: 23 April 2020 Time: 6 pm
• Age: 2 days
• Gender : Male
• Address : Hoskote
• LMP : 7/7/2019
• EDD : 14/4/2020
• Period of gestation: 38 weeks + 2 days
• Current Weight : 2.98Kg
4. • Place of delivery : MVJ MC & RH
• Mode of delivery: Full term normal vaginal delivery without
instrumentation
• Age of Mother at conception: 25 years
at delivery: 26 years
• Parity : P1 L1
• Blood group: Mother B+
• Father B+
• Baby B+
• Informant : Mother
• Reliablity of source : good
• Socioeconomic status: class 4 (modified BG Prasad )
• Date of examination : 26th April 2020
5. Chief complaint
• The baby was brought for routine check up, with normal newborn
care being provided and being evaluated for the same.
6. Antenatal History
• 1st Trimester
• Booked case at MVJ MC & RH
• Birth order : 1
• No H/O : fever with rashes & lymphadenopathy, excessive vomiting ,
fatigue, exposure to drugs or radiation , burning micturition ,
increased frequency of micturition , bleeding per vagina .
• Number of ANC visit: 2
• Dating scan done
• Folic acid taken
7. 2nd Trimester
• Quickening : 20th week of gestation
• Iron, calcium and folic acid supplements were taken
• No H/O : headache, blurring of vision, giddiness, swelling of lower
limbs that doesn’t subside on rest, fever with rashes, burning
micturition, discharge or bleeding per vagina , pain abdomen
• OGTT was done and was normal
• Scan: NT scan and foetal anomaly scan were done.
• Tetanus toxoid 2 doses 4 weeks apart were taken
• Number of ANC visits : 2
8. 3rd Trimester
• Foetal movement well perceived
• No H/O leaking or bleeding per vagina, pain abdomen, burning
micturition, swelling in the lower limbs that do not subside on rest.
No foul smelling discharge, PROM
• Iron and calcium supplements were taken
• Growth scan was done
• Number of ANC visits 2
• Total weight gain during pregnancy 11.5 kg
9. Post Natal History
• Gender of the baby : Male
• Weight at birth : 3 Kg
• Cried Immediately
• No H/O of NICU admission
• Breast feeding initiated within ½ an hour of delivery.
• Given adequately on demand during the day and night.
• Adequate sleep of 2-3 hours after every feed
• First passed urine and stool 5 hours after delivery
• Passage of urine of 5 times a day and stool 3 times a day for past 2
days
• Vitamin K supplementation of 1mgIM was administered
10. Immunization history
• BCG given at birth
• OPV given at birth
• Hep B given at birth
• Immunised till date
11. Family history
• No H/O of haemolytic disease liver disease , disease of gall bladder,
hereditary disease in the family
12. Summary
• A 3 day old term baby boy born to non consanguineous marriage by
normal vaginal delivery , who is exclusively breast fed ,with normal
growth and non significant past and family history came for regular
check up and was provided with normal newborn care and was
evaluated for the same.
13. General Physical Examination
Date of examination :26th April 2020
Appearance
The baby is alert and responsive in stage three of ---- , the skin colour is pink
and no sign of central or peripheral cyanosis.
APGAR Score
1min: 8
5min: 10
14. • Vitals
1) Temperature: 37 Celsius
2) Airway: Normal
3) Respiratory rate: 42 cycles/min and is thoraco-abdominal
4) Heart rate: 142 beats/min and blood pressure: 62/40 mm Hg
5) capillary refilling time: 2sec
6) pulses well felt and regular , no radioradial or radiofemoral delay.
• Anthropometry
1) Birth weight : 3Kg Current weight: 2.98Kg
2) Length: 53cm
3) Head circumference: 34cm
4) Chest circumference: 32.5cm
15. Head to toe examination
• Head: Normal
• Normal anterior and posterior fontanelle
• Face: normal
• Eyes: normal
• Ears: normal size and shape , elastic recoil present
• Nose: normal, mellia present
• Oral cavity and contents: normal
• Skin: Vernix caseosa present, Erythema neonatorum present, languo
present
16. • Chest: normal
• Umbilical cord and umbilicus: central, stump healing no discharge seen
• Genitals: penis normal, testes palpable
• Back: Normal
• Extremities-limbs, palms, soles, digits: normal, no pallor or icterus
present
• Orifices: all are present and patent.
17. • Pallor: absent
• Icterus: absent
• Clubbing: absent
• Cyanosis: absent
• Lympadenopathy: lymphnodes not palpable
• Oedema : absent
• Capillary refilling time : approximately 2 sec
18. Systemic examination
• Abdominal and genital examination
1) Inspection
Non distended
Umbilicus: central
Umbilical stump: healing, no discharge seen
Corresponding quadrant moves equally with respiration
No dilated veins or scars
Hernial orifices normal
Genatalia normal
19. 2) Palpation
No local rise in temperature
No tenderness
No palpable mass
4) Auscultation
bowel sounds heard
20. • Cardiovascular examination
S1 S2 heard
• Respiratory examination
normal vesicular breath sounds heard, bilateral equal air entry
• Central nervous system examination
Higher mental functions normal for age
Reflexes
Rooting reflex: present
Sucking reflex: present
Moro’s reflex: present
Asymetric tonic neck reflex: present
Palmar grasp reflex: present
