GENERAL DATA
Name: PASCUA, Baby girl
Age/Sex: NB/F
Address: 1284 G. Tuazon St. San Andres Bukid Manila
Date of Birth: July 16, 2009
Date & Time Admitted: July 16, 2009 11:25am
History of Present Illness
This is a case of a newborn live baby girl born pre term to a 21 y/o G2P2 (1-1-0-2), 34-35 weeks AOG via LTCS x transverse lie at OMMC. Upon birth, patient was observed with subcostal retractions, hence admission.
Pre-natal History
(+) PNCU x 3 at Fermin health center (-) laboratory exams (-) maternal illness (+) multivitamins
(-) ferrous sulfate
(-) use of illicit drugs, use of teratogenic substances, exposure to radiation (-) comorbid factors
Obstetrical History
G2P1 (2-0-0-1) G1 2008 F FT NSD Home G2 present pregnancy
Physical Examination
Gen. Survey: good activity, good cry, good tone,
(-)cardio-respiratory distress
Skin: pinkish color, good skin turgor, (-)rashes, (-)
hematoma, (-) desquamation
VS: HR=150 RR=48
Head: (-)caput, (-)molding, (-)craniotabes,
(-)cephalhematoma
Face: (-)asymmetry Eyes: (-)conjunctivitis, (-)discharge
Physical Examination
ENT: (+) patent nose, (-)cleft lip, (-)cleft palate, (+) CBS
Abdomen: (+) flat, (-)masses, (+) 2A:1V
Genitals: normal Trunk & Spine: (-) spina bifida, (+) deformity, (-) sydactilism, (+)club foot, (+) full and equal pulses Reflexes: (+) Moro, (+) sucking, (+) grasping
Physical Examination
Antropometrics: BL=44cm APGAR score: 7,8 1min 5min
BW=1.7kg
HC=30cm CC=27.5cm AC=27cm
appearance 1
pulse grimace activity respiration Total 1 2 1 2 7
1
2 2 1 2 9
Assessment
Live baby girl, born pre-term, to a 21y/o G2P2 (2-0-0-2) mother, 34-35 weeks AOG, via LTCS. Respiratory distress syndrome
Prematurity