Healthy Newborn Patient Presentation

sipebike's version from 2018-03-13 04:07


Baby girl (boy) Stoker is a 20 hr old baby born to a 24 yr old G2 P2 AB0 caucasian mother at 40 weeks 2 days gestation via SVD. The mother is GBS - and no Abx given. The baby has a low Early Onset Sepsis (EOS) risk. Baby was Coombs - . Apgars were 7 and 9 at 1 and 5 minutes, respectively. Birth length was 50 cm, HC was 35 cm, birth weight was 3.5 kg, baby was LGA. Current weight is 3.2 kg, so the baby has had a 9% weight loss. Most recent temperature was 36.4 ℃, heart rate was 130, respiratory rate was 40. TcBilirubin was 5mg/dL @ 18 hrs which is intermediate risk. She is currently breast feeding with supplementation. The baby has voided and has stooled. Congenital heart screen passed. Hearing screen passed bilaterally. Vitamin K and Erythromycin eye drops given. Hep B vaccine deffered.


Mother had gestational HTN but protein urinalysis negative.


General: Vigorous
Skin: Pink, nevus simplex noted on forehead and left thigh
Head: NC/AT, Anterior Fontanelle: Open, nares patent, palate fused, no neonatal teeth, Ears elastic
Reflexes: Red reflexes bilaterally, root, suck, grasp, moro
Neck: no masses
Chest: no crepitus along clavicles, chest symmetrical , no retraction
Heart: Heart sounds normal S1 and S2, no murmurs or gallops
Lungs: Clear to auscultation bilaterally
Abdomen: normoactive bowel sounds, Liver edge 2 cm from costal margin, no abnormal masses
Hips: Barlow negative, Ortolani negative, femoral pulses equal bilaterally
Genitals: Anus patent
Female: Labia majora and minora normal, with white discharge
Legs: can be stretched to neutral position, upward babinski reflex
Umbilical cord: bloody, dry, 3 vessels, with cord clamp
Spine: straight, spinous processes felt, no sacral dimpling
Assessment / Plan:
“20 hr old full-term baby girl is okay to home today as long as the mother is feeling well. I do not recommend antibiotics, urine toxicity check or blood culture.”