SOUTHWESTERN

UNIVERSITY
MEDICAL CENTER
DEPARTMENT OF PEDIATRICS
SLIDESMANIA.COM
 GENERAL DATA
Baby J, live, female, 35 weeks, late
preterm,
1,745 g , LBW, AGA, delivered via CS
secondary to PPROM and previous CS
(Placenta Previa and NRFHRP), on October
09, 2021, 8:20 am, AS 9,9, RBOW x 52
hours, clear amniotic fluid at Southwestern
University Medical Center.
SLIDESMANIA.COM
 PRENATAL HISTORY

Mother M.J, 37 years old, G3P1 (0110) 32 2/7

weeks AOG by LMP, a Roman Catholic,
residing in Carcar, Cebu.
LMP: 2/23/21, EDC: 11/11/21.
SLIDESMANIA.COM
 PRENATAL HISTORY
● pregnancy test was done at last week of march,
found out positive

● spotting was noted at first week of April prompted

consultation at Chong Hua Medical Hospital, UTZ
was done confirming 6 weeks AOG and was given
Dydrogesterone (Duphaston)

● started first prenatal check up at SWU-MC on

June 10, 2021. 15 weeks AOG by LMP followed by 9
SLIDESMANIA.COM

subsequent visits.
 PRENATAL HISTORY
● Quickening was noted at 18 weeks AOG.

● Routine lab tests done were HIV, HBsAg, VDRL were all
nonreactive. UA was unremarkable, blood typing showed
O+, Blood chemistry showed increase creatinine, ALT, LDH
and elevated glucose on 75 grams OGTT test. CBC showed
neutrophilia and thyroid panel was inconclusive.

● Maternal illness noted were chronic hypertension, overt DM,

and subclinical hyperthyroidism. Mother was prescribed
with methyldopa 250mg 2 tabs q 6 hr and aspirin 80mg 2
tabs HS until 36 weeks, insulin for DM
SLIDESMANIA.COM
 PRENATAL HISTORY
● patient has been taking folic acid + ferrous sulfate,
multivitamins, Vit C and Calcium once/day with good
compliance

● Mother had last prenatal check up at 31 2/7 weeks

AOG by UTZ

● Mother BMI 30.8 - obese class I, BP 140/100 mmhg,

FH 29 cm, FHB 148 bpm.
SLIDESMANIA.COM
 PRENATAL HISTORY
Order Year Delivery AOG Gender weight Hospital Complications

1 2019 complete 6 - - St. -

abortion weeks Vincent
hospital

2 2020 CS 29 Male - VSMMC neonatal sepsis

weeks

3 2021 Present
pregnancy
SLIDESMANIA.COM
 INTRANATAL HISTORY
● 52 hours prior to delivery, mother was just lying down and suddenly
noted a watery vaginal discharge “wa may baho, clear ra siya, dili
kaayo daghan tong naghigda pako, nidaghan na tong nagbarog
nako”, no associated abdominal pain, no headache, nor blurring of
vision. No consult was done.

● 46 hours prior to delivery, FH: 29 CM, EFW: 2,170 g, FHT: 138 bpm,
1cm dilated, slightly effaced, station -5, cephalic presentation,
position: right occiput transverse, with pooling of clear amniotic
fluid and was subsequently admitted. Given erythromycin 1 tab q 6
hr, Ampicillin 2g IVTT q 6 hr, Dexamethasone 6 mg q 12hr for 4
doses
SLIDESMANIA.COM
 INTRANATAL HISTORY
● 20 hours prior to delivery, mother had UTZ showed
oligohydramnios, high lying, grade 2.

● 5 hours prior to delivery, mother had increased in watery

vaginal discharge associated with continuous uterine
contractions

● 2 hours prior to delivery, 2cm dilatation, 50% effaced, station -3,

cephalic, scheduled for CS delivery. Mother delivered by repeat
low segment transverse cesarean section a live, female
neonate, 35 weeks, AS 9,9, 1,745 g, LBW, AGA
SLIDESMANIA.COM
 PHYSICAL EXAM
1 1

2 2

2 2

2 2

2 2

9 9

9,9
no resuscitation done
EINC performed
SLIDESMANIA.COM
 PHYSICAL EXAM
3

2
SLIDESMANIA.COM

15
 PHYSICAL EXAM

2
29 ----------35
2

3
SLIDESMANIA.COM

14 35 weeks
 PHYSICAL EXAM
General survey: awake, not in respiratory distress, good cry.

Vital signs:
Temperature: 35. 8 C
Heart rate: 137 bpm
Respiratory rate: 52 cpm
02 sat: 99%
SLIDESMANIA.COM
 PHYSICAL EXAM
ANTHROPOMETRIC DATA

Birthweight : 1, 745 grams (on the 10th Percentile)

Birth length: 42 cm (between 10th and 25th Percentile)
Head circumference: 31cm ( on the 25th Percentile )
Chest circumference: 26 cm
Abdominal girth: 22 cm
SLIDESMANIA.COM
 PHYSICAL EXAM

35 weeks
Birthweight: 1, 745 grams
(on the 10th percentile)
SLIDESMANIA.COM
 PHYSICAL EXAM

35 weeks
Birth length: 42 cm
(between 10th and 25th percentile)
SLIDESMANIA.COM
 PHYSICAL EXAM
35 weeks
Head circumference: 31 cm
(on the 25th percentile)
SLIDESMANIA.COM
 PHYSICAL EXAM

Birthweight : 1, 745 grams

(on the 10th Percentile)
Birth length: 42 cm
(between 10th and 25th
percentile)
Head circumference: 31 cm
(on the 25th Percentile )

● Appropriate for gestational

age
SLIDESMANIA.COM
 PHYSICAL EXAM
Skin – acrocyanotic, cracking with pale ares and rare
veins, no lesions, no rashes, warm to touch, thinning
lanugo.
HEENT – normocephalic, anterior fontanel open and not
bulged nor depressed, posterior fontanel closed, no eye
discharges, no alar flaring, no lymphadenopathy, no
neck masses, no ear discharges, well-curved pinna, soft
but ready recoil
Mouth – no gross deformities, moist lips.
Chest and Lungs – No chest deformities, equal chest
expansion, clear breath sounds, no subcostal retractions,
stippled areola, 1-2 mm bud.
SLIDESMANIA.COM
 PHYSICAL EXAM
Heart – distinct heart sounds, regular rate and rhythm,
no murmurs.
Abdomen – globular, non-distended, no
organomegaly, clean and dry umbilical stump,
normoactive bowel sounds
Genitalia – majora large, minora small
Anus – patent
Extremities – plantar crease anterior transverse only, no
polydactyly nor syndactyly, CRT <2 sec.
Primitive Reflexes – (+) palmar grasp, (+) rotting, (+)
Babinski reflex, (+) Moro reflex, (-) tonic neck
SLIDESMANIA.COM
 ADMITTING DIAGNOSIS:
Live, female, 35 weeks, late preterm,
1,745 g, LBW , AGA, delivered via CS
secondary to PPROM and previous CS
(Placenta Previa and NRFHRP), AS 9,9,
RBOW x 52 hours, clear amniotic fluid
SLIDESMANIA.COM
 Date
HOSPITAL PROGRESS
Progress Notes Management Laboratories

Day 0 Subjective: good cry, good activity, no jaundice, voided, Plans: Hematology:
October 09, 2021 not yet defecated. ● NPO temporarily Blood Type: O+
● IVF D10W 70 cc/kg/day RBC: 4.41
Objective: ● Keep OGT in place Hgb: 18.10 g/dL (15.00-18.00)
Awake, not in respiratory distress. ● Secure EBM and store Hct: 50% (38.90-49.10)
HR: 137 bpm ● Ampicillin (AD= 160 mkD) for 7 days Plt: 291
RR: 52cpm ● Amikacin (AD= 14.3 mkD) for 7 days MCV: 113.50 MCH: 41.10 pg
Temp: 35.8C ● Continue HGT request every 8hrs MCHC: 36.20g/dL RDW-CV 16.20%
O2sat:99% ● Monitor I & O q shift PDW 11.60 PCT: 0.26%
● Routine Newborn Care: P-LCC: 59 P-LCR: 20.40%
Skin: pink, warm to touch, no cyanosis, no lesions, good ● - Suction Secretion as needed WBC: 13.12
skin turgor, no rashes. ● - Daily cord dressing with water N: 63.70% L: 32.2% M: 2.6% E: 0.4% B:
HEENT: normocephalic, symmetrical facial features, ● - Thermoregulate temperature @36.5-37.5 C 1.1%
anterior fontanel open not bulged, posterior fontanel ● Continue CPAP for 24hrs and observe QRCP: 8.0 mg/dL
closed, no eye discharges, no ear discharges, (+) alar ● Fi02 30%, humidifier 2, PEEP 4, TRF 4
flaring, no lymphadenopathy, no gross deformities, moist ● weigh baby daily Clinical Chemistry:
lips. ● hold hepa b vaccine until wt >2000 g Blood gas analysis
C/L: No chest deformities, equal chest expansion, clear ● Continue vital signs monitoring q hourly pH: 7.293
breath sounds, (+) subcostal retractions. ● Refer for any unusualities pCO2: 46.8 mm Hg
Heart: distinct heart sounds, regular rate and rhythm, no ● CCHD screening at 24hrs of life pO2: 410.0 mm Hg
murmurs. ● Hearing test at 24hrs of life HCO3-: 22.5mmol/L
Abdomen: globular, not distended, no organomegaly, ● Newborn screening at 24hrs of life BE(ecf): -4.00 mEq/L
clean and dry umbilical stump, normoactive bowel O2 sat: 100%
sounds. Temperature: 37.5 C
Genitalia: No gross deformities, majora large, minora Blood Glucose:
small. HGT 10/9/21: @10:20am: 56 mg/dL,
Anus: patent.
fluid intake: 95cc @12nn: 69 mg/dL, @6pm: 89 mg/dL
Extremities: no deformities, strong peripheral pulses fluid output: 70 cc HGT 10/10/21: @2am: 100 mg/dL,
Reflex: (+) palmar grasp, (+) rotting, (+) Babinski reflex, fluid balance: 25 cc @10am: 96 mg/dl, @6pm: 100mg/dl
(+) Moro reflex, (-) tonic neck urine output: 1.67 cc/kg/hr @2am: 86 mg/dl
SLIDESMANIA.COM

Assessment: X-RAY impression: (AP)

T/c transient tachypnea of the newborn, current weight: 1,745 g Clear lungs, widened superior mediastinum
t/c RDS, t/c: neonatal sepsis from a prominent thymic shadow.
 Date
HOSPITAL PROGRESS
Progress Notes Management Laboratories

Day 1 Subjective: thermoregulated, good suck, good cry, Plans: Labs:

October 10, good activity, (+) jaundice, voided and defecated ● NPO temporarily Total bilirubin: 10.53 mg/dl
2021 ● Continue IVF with D10 IMB (0.18-1.23)
Objective: Awake, not in respiratory distress 80cc/kg/hr Direct Bilirubin: 0.22 mg/dl
HR: 148 bpm ● Keep OGT in place (0.0-0.19)
RR: 46 cpm ● Continue Phototherapy Indirect bilirubin: 10.31
Temp: 36.5 C ● CPAP (FiO2 25 %) mg/dl (0.15-0.70)
O2 sat: 95% ● Ampicillin gD2 160 mkD
● Amikacin gD2 14 mkD high risk zone (Bhutani
Skin: no cyanosis, no rashes, (+) jaundice at face, ● Securer EBM and store chart) at 21 hours of life
chest, lower abdomen and thighs, cracking, pale areas, ● Routine Newborn Care
rare veins ● -suction secretion as needed Follow up blood culture
HEENT: normocephalic, symmetrical facial features, no ● -daily cord dressing result
eye discharge, no ear discharge, well curved pinna, ● -thermoregulate temperature HGT request every 8 hours
soft but ready recoil, no lymphadenopathy at 36.5 to 37.5
C/L: no chest deformity, equal chest expansion, clear ● Monitor vital sign every hour
breath sound, no subcostal retraction ● Monitor input and output fluid intake: 134 cc
Heart: distinct heart sound, normal rate and rhythm, no every shift fluid output: 115 cc
heaves, no murmurs ● Refer for any unusualness fluid balance: 19 cc
Abdomen: globular, not distended, no organomegaly, urine output: 2.74 cc/kg/hr
clean umbilical stump
Reflexes::(+) rooting, (+) palmar grasp, (+) moro reflex current weight: 1,750 g
SLIDESMANIA.COM

Assessment: (+) jaundice at 21 hrs of life, high risk

zone via Bhutani chart, Zone 3 via Kramer’s staging
 Date HOSPITAL PROGRESS
Progress Notes Management Laboratories

Day 2 Subjective: Good activity, good cry, no tachypnea, no Plans: Labs:

October 11, vomiting (+) Jaundice, voided and defecated, unstable O2 ●shift from trophic feeding to NPO HGT at 2am: 86 mg/dL
sat (desaturation) temporarily then observe OGT secretions
2021
●Continue IVF with D10 IMB 90 cc/kg/day
Objective: Awake, not in respiratory distress, attached to + Calcium gluconate 30 mkD + Aminostril fluid intake: 153.8 cc
CPAP, with OGT, under phototherapy, attached to neonatal
2.5 mkD fluid output: 140 cc
monitor
●CPAP FiO2 21 % to FiO2 25% fluid balance: 13.8 cc
HR: 140 bpm
RR: 50 cpm ●continue phototherapy urine output: 3.34
Temp: 36.8 C ●Apply Mupirocin IV site QID cc/kg/hr
O2 sat: 99% ●Ampicillin gD3 160 mkD
●Amikacin gD3 14 mkD current weight:
Skin: (+) jaundice at face and chest , (-) lesions, (-) rashes, ●Monitor v/s hourly
warm to touch, with good skin turgor ●Monitor I & O q shift
HEENT: normocephalic, non-bulging fontanels, no eye ●Continue newborn care
discharge, no ear discharge, no alar flaring ●Follow-up culture and sensitivity test
C/L: Equal chest expansion, no chest deformity, clear breath result
sound (+)minimal subcostal retraction ●Refer for any unusualities
Heart: distinct heart sound, normal rate and rhythm, no heaves, ●Repeat CBC, QRCP & TBDB
no murmurs
Abdomen: globular, (+) minimal abdominal distention, clean
and dry umbilicus, non erythematous and without discharges,
normoactive bowel sounds
Genitalia: Grossly female, prominent clitoris, majora large,
minora small
Extremities: No gross deformities, good peripheral pulse
SLIDESMANIA.COM

Assessment: (+) jaundice at 56 hours of life, Zone 2 via

Kramer’s staging, t/c neonatal sepsis, t/c: necrotizing
enterocolitis
 Date
HOSPITAL PROGRESS
Progress Notes Management Laboratories

Day 3 Subjective: Good activity, good cry, no tachypnea, no Plans: Labs:

October 12, vomiting (+) Jaundice, voided and defecated ●shift NPO to trophic feeding at 5mL q 3hrs HGT at 2am: 95 mg/dL
2021 EBM, monitor OGT secretions
Objective: Awake, not in respiratory distress, attached to ●Continue IVF with D10 IMB 90 cc/kg/day high intermediate risk
CPAP, with OGT, under phototherapy, attached to neonatal ●continue apply Mupirocin at IV site QID zone (Bhutani chart) at
monitor
●increase Ampicillin gD4 229 mkD 69 hours of life
HR: 137bpm
●Amikacin gD4 14 mkD
RR: 56 cpm
Temp: 36.7 C ●continue CPAP (FiO2 21%) fluid intake: 200.1 cc
O2 sat: 99% ●continue phototherapy fluid output: 165 cc
●monitor thermoregulation fluid balance: 35.1 cc
Skin: (+) jaundice at face and chest , + mottling (-) lesions, (-) ●Monitor v/s hourly urine output: 3.93
rashes, warm to touch, with good skin turgor ● Monitor I & O q shift (3.6 cc/kg/hr) cc/kg/hr
HEENT: normocephalic, non-bulging fontanels, no eye ●Continue newborn care
discharge, no ear discharge, no alar flaring ●Follow-up culture and sensitivity test current weight: 1,800g
C/L: Equal chest expansion, no chest deformity, clear breath result
sound ●Refer for any unusualities
Heart: distinct heart sound, normal rate and rhythm, no heaves,
no murmurs
Abdomen: globular, not distended, clean and dry umbilicus non
erythematous and without discharges, normoactive bowel
sounds
Genitalia: Grossly female, prominent clitoris, majora large,
minora small
Extremities: No gross deformities, good peripheral pulse, CRT
<2 sec
SLIDESMANIA.COM

Assessment: (+) jaundice at 72 hours of life, high

intermediate risk zone via Bhutani chart, Zone 2 via
Kramer’s staging
 Date
HOSPITAL PROGRESS
Progress Notes Management Laboratories

Day 4 Subjective: Good activity, good cry, no tachypnea, no Plans: Labs:

October 13, vomiting (+) Jaundice, voided and defecated ●increase OGT feeding by 5 mL every 3 HGT at 10AM: 110
2021 hours tolerated until 15 mL, monitor mg/dL, at 6 pm: 128
Objective: Awake, not in respiratory distress, with OGT, OGT secretions mg/dL
under phototherapy, attached to neonatal monitor ●Continue IVF with D10 IMB 90
HR: 148bpm
cc/kg/day fluid intake: 268 cc
RR: 47 cpm
●check for the patency of OGT fluid output: 130 cc
Temp: 37.0 C
O2 sat: 100% ,abdominal distension,vomiting. fluid balance: 138 cc
●continue apply Mupirocin at IV site QID urine output: 3.10
Skin: (+) jaundice at face and back , + mottling (-) lesions, ●Ampicillin gD6 229 mkD (10 pm) cc/kg/hr
(-) rashes, warm to touch, with good skin turgor continue until 10 days
HEENT: normocephalic, non-bulging fontanels, no eye ●Amikacin gD6 14 mkD (11 am) current weight: 1, 700g
discharge, no ear discharge, no alar flaring continue until 10 days
C/L: Equal chest expansion, no chest deformity, clear ●discontinue CPAP, shift to 02
breath sound inhalation at 1 lpm via nasal cannula
Heart: distinct heart sound, normal rate and rhythm, no ●continue phototherapy
heaves, no murmurs ●repeat TB DB, QCRP on 10/14/21
Abdomen: globular, not distended, clean and dry umbilicus ●monitor thermoregulation
non erythematous and without discharges, normoactive
●Monitor v/s hourly
bowel sounds
● Monitor I & O q shift
Genitalia: Grossly female, prominent clitoris, majora large,
minora small ●Continue newborn care
Extremities: No gross deformities, good peripheral pulse, ●Follow-up culture and sensitivity test
CRT <2 sec result
SLIDESMANIA.COM

●Refer for any unusualities

Assessment: (+) jaundice at 106 hours of life, Zone 1 via
Kramer’s staging
 Date
HOSPITAL PROGRESS
Progress Notes Management Laboratories

Day 5 Subjective: Good activity, good cry, no tachypnea, no Plans: discontinue HGT
October 14, vomiting, voided and defecated ● OGT feeding at 15mL q 3hrs monitoring
2021 EBM, monitor OGT secretions
Objective: Awake, not in respiratory distress ● Continue IVF with D10 IMB 110
HR: 145bpm cc/kg/day fluid intake: 195 cc
RR: 42 cpm
● check for the patency of OGT fluid output: 125 cc
Temp: 36.7 C
,abdominal distension,vomiting. fluid balance: 70 cc
O2 sat: 100%
● continue apply Mupirocin at IV site urine output: 2.98
Skin: (+) jaundice at face , + mottling (-) lesions, (-) rashes, QID cc/kg/hr
warm to touch, with good skin turgor ● Ampicillin gD7 229 mkD
HEENT: normocephalic, non-bulging fontanels, no eye ● Amikacin gD7 14 mkD current weight: 1,660 g
discharge, no ear discharge, no alar flaring ● decrease O2 inhalation at 0.5 lpm
C/L: Equal chest expansion, no chest deformity, clear via nasal cannula and maintain O2
breath sound sat at >95%
Heart: distinct heart sound, normal rate and rhythm, no ● continue phototherapy
heaves, no murmurs ● monitor thermoregulation
Abdomen: globular, not distended, clean and dry umbilicus ● Monitor v/s hourly
non erythematous and without discharges, normoactive ● Monitor I & O q shift
bowel sounds
● Continue newborn care
Genitalia: Grossly female, prominent clitoris, majora large,
● Follow-up culture and sensitivity
minora small
Extremities: No gross deformities, good peripheral pulse, test result
CRT <2 sec ● follow up TB DB and CRP results
● Refer for any unusualities
SLIDESMANIA.COM

Assessment: (+) jaundice at 114 hours of life, Zone 1 via

Kramer’s staging
 Date
HOSPITAL PROGRESS
Progress Notes Management

Day 6 Subjective: Good activity, good cry, no tachypnea, no Plans:

October 15, vomiting, voided and defecated ● switch to cup feeding 5 mL with
2021 aspiration precaution and the fluid intake: 200 cc
Objective: Awake, not in respiratory distress remaining 20 mL via OGT, fluid output: 110 cc
HR: 150bpm monitor OGT secretions fluid balance: 90 cc
RR: 48 cpm
● check for the patency of OGT urine output: 2.71
Temp: 37.2 C
,abdominal distension,vomiting. cc/kg/hr
O2 sat: 100%
● Ampicillin gD8 229 mkD
Skin: (+) jaundice at face , + mottling (-) lesions, (-) rashes, ● Amikacin gD8 14 mkD
warm to touch, with good skin turgor ● continue phototherapy weight: 1,690 g
HEENT: normocephalic, non-bulging fontanels, no eye ● monitor thermoregulation
discharge, no ear discharge, no alar flaring ● Monitor v/s hourly
C/L: Equal chest expansion, no chest deformity, clear ● Monitor I & O q shift
breath sound ● Continue newborn care
Heart: distinct heart sound, normal rate and rhythm, no ● Follow-up culture and sensitivity
heaves, no murmurs test result
Abdomen: globular, not distended, clean and dry umbilicus ● Refer for any unusualities
non erythematous and without discharges, normoactive
bowel sounds
Genitalia: Grossly female, prominent clitoris, majora large,
minora small
Extremities: No gross deformities, good peripheral pulse,
CRT <2 sec
SLIDESMANIA.COM

Assessment: (+) jaundice at 6 days of life, Zone 1 via

Kramer’s staging
 Date
HOSPITAL PROGRESS
Progress Notes Management

Day 7 Subjective: Good activity, good cry, no tachypnea, no Plans:

October 16, vomiting, voided and defecated ● increase cup feeding 14 mL with fluid intake: 234.2 cc
2021 aspiration precaution and the fluid output: 135 cc
Objective: Awake, not in respiratory distress remaining 16 mL via OGT, monitor fluid balance: 99.2 cc
HR: 149bpm OGT secretions urine output: 3.22
RR: 45 cpm
● check for the patency of OGT cc/kg/hr
Temp: 36.8 C
,abdominal distension,vomiting.
O2 sat: 100%
● continue apply Mupirocin at IV site
Skin: (-) jaundice (-) lesions, (-) rashes, warm to touch, QID
with good skin turgor ● Ampicillin gD9 229 mkD current weight: 1,625 g
HEENT: normocephalic, non-bulging fontanels, no eye ● Amikacin gD9 14 mkD
discharge, no ear discharge, no alar flaring ● monitor thermoregulation
C/L: (+) pectus excavatum, Equal chest expansion, clear ● Monitor v/s hourly
breath sound ● Monitor I & O q shift
Heart: distinct heart sound, normal rate and rhythm, no ● Continue newborn care
heaves, no murmurs ● Follow-up culture and sensitivity
Abdomen: globular, not distended, clean and dry umbilicus test result
non erythematous and without discharges, normoactive ● Refer for any unusualities
bowel sounds
Genitalia: Grossly female, prominent clitoris, majora large,
minora small
Extremities: No gross deformities, good peripheral pulse,
CRT <2 sec
SLIDESMANIA.COM

Assessment: clinically stable at 7 days of life

 Date
HOSPITAL PROGRESS
Progress Notes Management

Day 8 Subjective: Good activity, good cry, no tachypnea, no Plans:

October 17, vomiting (+) Jaundice, voided and defecated ● increase cup feeding 16 mL with fluid intake: 242.4 cc
2021 aspiration precaution and the fluid output: 160 cc
Objective: Awake, not in respiratory distress remaining 14 mL via OGT, fluid balance: 82.4 cc
HR: 145 bpm monitor OGT secretions urine output: 3. 82
RR: 50 cpm
● check for the patency of OGT cc/kg/hr
Temp: 37.0 C
,abdominal distension,vomiting.
O2 sat: 100%
● Ampicillin gD10 229 mkD
Skin: (-) jaundice at face , (-) mottling (-) lesions, (-) ● Amikacin gD10 14 mkD current weight: 1,660 g
rashes, warm to touch, with good skin turgor ● monitor thermoregulation
HEENT: normocephalic, non-bulging fontanels, no eye ● Monitor v/s hourly
discharge, no ear discharge, no alar flaring ● Monitor I & O q shift
C/L: (+) pectus excavatum) Equal chest expansion, clear ● Continue newborn care
breath sound ● Refer for any unusualities
Heart: distinct heart sound, normal rate and rhythm, no
heaves, no murmurs
Abdomen: globular, not distended, clean and dry umbilicus
non erythematous and without discharges, normoactive
bowel sounds
Genitalia: Grossly female, prominent clitoris, majora large,
minora small
Extremities: No gross deformities, good peripheral pulse,
CRT <2 sec

Assessment: clinically stable at 8 days of life

SLIDESMANIA.COM
 Date
HOSPITAL PROGRESS
Progress Notes Management

Day 9 Subjective: Good activity, good cry, no tachypnea, no Plans:

October 18, vomiting, voided and defecated ● cup feeding 16 mL with aspiration fluid intake: 242.4 cc
2021 precaution and the remaining 14 mL fluid output: 130 cc
Objective: Awake, not in respiratory distress via OGT, monitor OGT secretions fluid balance: 112.4
HR: 140bpm ● check for the patency of OGT urine output: 3.1 cc/kg/hr
RR: 50 cpm
,abdominal distension,vomiting
Temp: 36.8 C
● monitor thermoregulation
O2 sat: 100%
● discontinue antibiotics
Skin: (-) jaundice at face , (-) mottling (-) rashes, warm to ● Monitor v/s hourly
touch, with good skin turgor ● Monitor I & O q shift current weight: 1,665 g
HEENT: normocephalic, non-bulging fontanels, no eye ● Continue newborn care
discharge, no ear discharge, no alar flaring, (+) lesion at the ● Refer for any unusualities
nose
C/L: (+) pectus excavatum, Equal chest expansion, clear
breath sound
Heart: distinct heart sound, normal rate and rhythm, no
heaves, no murmurs
Abdomen: globular, not distended, clean and dry umbilicus
non erythematous and without discharges, normoactive bowel
sounds
Genitalia: Grossly female, prominent clitoris, majora large,
minora small
Extremities: No gross deformities, good peripheral pulse, CRT
<2 sec
SLIDESMANIA.COM

Assessment: clinically stable at 9 days of life

 Date
HOSPITAL PROGRESS
Progress Notes Management

Day 10 Subjective: Good activity, good cry, no tachypnea, no Plans:

October 19, vomiting, voided and defecated ● cup feeding 30 ml fluid intake: 242.4 cc
2021 ● remove OGT fluid output: 160 cc
Objective: Awake, not in respiratory distress ● check for,abdominal fluid balance: 82.4 cc
HR: 141 bpm distension,vomiting urine output: 4 cc/kg/hr
RR: 45 cpm
● monitor thermoregulation
Temp: 36.9
● Monitor v/s hourly
O2 sat: 100%
● Monitor I & O q shift
Skin: (-) jaundice at face , (-) mottling (-) rashes, warm to ● Continue newborn care
touch, with good skin turgor ● weigh baby daily current weight: 1,665 g
HEENT: normocephalic, non-bulging fontanels, no eye ● Follow-up culture and sensitivity test
discharge, no ear discharge, no alar flaring, (+) lesion at the result
nose ● Refer for any unusualities
C/L: (+) pectus excavatum, Equal chest expansion, clear
breath sound
Heart: distinct heart sound, normal rate and rhythm, no
heaves, no murmurs
Abdomen: globular, not distended, clean and dry umbilicus
non erythematous and without discharges, normoactive bowel
sounds
Genitalia: Grossly female, prominent clitoris, majora large,
minora small
Extremities: No gross deformities, good peripheral pulse, CRT
<2 sec
SLIDESMANIA.COM

Assessment: clinically stable at 10 days of life

Thank you!
SLIDESMANIA.COM