Newborn Admit Note H&P
CC: Newborn HPI Newborn baby _ born to a _ yo G_P_ at _ and _/_ weeks EGA who presented in _ labor with/without SROM at _/_/_. Total time with ruptured membranes was _. She was (not) induced/augmented and progressed well to complete over about _ hours. Patient then began to push, and at this time of 2nd stage of labor had _ complications. She delivered a vigorous baby in _ position via vaginal delivery. There was _ nuchal cord reduced by _. Baby was immediately placed on mother’s abdomen and cord was clamped after _ minutes. Baby with _ cry and APGARS at 1 and 5 minutes of _ and _, respectively. Maternal Prenatal Hx: ABO/Rh: _ Antibody: _ Hgb: _ Pap: _ Rubella: _ Varicella: _ VDRL: _ Urine Cx: _ HBsAg: _ HIV: _ CT: _ NG: _ MSAFP: _ 1 hr GTT: _ GBS: _ PPD: _ Pregnancy Complications: _ Pertinent Family History: _ Physical Exam .vitals .birthweight GEN: NAD HEENT: Red Reflex seen b/l, external ears w/o tags or pits, AFOF, + molding, No cephalohematoma, hard palate intact NECK: Negative clavicular fx CV: RRR, no MRG RESP: CTAB, no distress ABD: nl BS, soft, nd, no masses, no guarding RECTAL: Patent, no masses GU: Normal female genitalia for newborn, patent urethra and vagina PULSES: 2+ femoral pulses b/l EXTR: No swelling or edema in the BLE, No acrocyanosis, Negative Ortoloni and Barlo b/l SKIN: No rashes or lesions thorughout body, no spinal tufts of hair or dimples, No Jaundice NEURO: MAEE, good tone, +Morro, +Grip in all four extremities, +Galant b/l Assessment and Plan: DOL#_ for this _ and _/_ week EGA _ born via _ complicated by _ to a _ yo G_P_->_ mom who is _ (blood type) and Antibody _ with prenatal course that was complicated by _ and normal PNL except _ with adequate/inadequate intrapartum prophylaxis. Maternal Blood type _: (Do not) send cord blood for HDN w/u Breast Feed on demand with support as needed Hepatitis B Vaccination: Give _ State NBS per routine, CHD screen per routine, Hearing Screen per routine Routine couplet care otherwise.