NEONATAL HISTORY

GENERAL DATA
This is the case RAMON, Baby GIRL, newborn, Filipino, born to a roman catholic mother on February
5, 2019 8 pm at R1MC and will be residing at Manaoag, Pangasinan. The informant is the mother with a
reliability of 95%.

PAST MATERNAL MEDICAL HISTORY

Mother had breast surgery for fibroadenoma in 2015 at R1MC. She had TB but already completed
treatment since 2014 and was cured. She has no hypertension, heart disease, cerebrovascular disease, blood
dyscrasias, diabetes, bronchial asthma, or malignancy. She is allergic to chicken and seafoods but no allergy to
medications.

OB HISTORY

OB score: G8P7 (6-1-0-6)

Weight Sex Institution Mode Outcome

G1(2000) Unrecalled male Home NSD w/o complication
G2(2001) Unrecalled Female Home NSD w/o complication
G3(2003) Unrecalled Male Home NSD w/o complication
G4(2005) Unrecalled Male Home NSD w/o complication
G5(2010) Unrecalled Male Home NSD w/o complication
G6(2013) Unrecalled Female Home NSD w/o complication
G7(2015) 3.5kg Male R1MC LSCS (Non Died
reassuring
fetal status)
G8(2019) Present pregnancy

PRE-NATAL HISTORY
Mother was cognizant of pregnancy at around 3 months AOG due to amenorrhea from and irregular
menstruation of every 2-3 months confirmed by pregnancy test done at home. She claimed that the pregnancy
was unplanned but wanted and with no attempts of abortion.
During the 1st trimester there was occasional nausea and vomiting but tolerated, no other signs and
symptoms experienced. She was unable to recall when was quickening started. On the 2 nd and 3rd pregnancy, the
mother had urinary frequency but no complains of dysuria, febrile episodes, nausea and vomiting, and cough and
colds. The mother had no prenatal check-up done and no multivitamins taken. There was no exposure to illicit
drugs, cigarette smoke and alcohol.

PERINATAL HISTORY
5 hours PTA mother experienced hypogastric pain radiating at the lumbosacral area 3-4/10 in intensity
occurring every 30 minutes with associated ruptured bag of water. 30 mins PTA, the hypogastric pain increased
in intensity 8-9/10 with 60 seconds in duration every 5-10 minutes, spotting was also noted, hence was brought
to R1MC.
At the ER, IE revealed 5cm dilated cervix 60-70% effaced, station -2, Ruptured BOW. Patient was
immediately scheduled for emergency LSCS for non reassuring fetal status.

LMP: PMP: AOG: EDC:

May 1st week 2018 unrecalled 40 weeks by LMP February 1st week by
LMP

NATAL HISTORY
Patient was born via LSCS for non reassuring fetal status. Upon birth there was noted 3 cord loop,
patient was limp, no respiratory effort and cyanotic HR < 70 beats per minute. Patient was dried, umbilical cord
was immediately cut, neonate was transferred to the neonatal resuscitation table. Neonatal resuscitation
procedure was done, positive pressure ventilation and CPR done, HR became 120 beats per minute however the
patient was still limp, no respiratory effort, pinkish with bluish extremities, hence was immediately intubated,
transferred to NICU and subsequently admitted. Patient was hooked immediately to mechanical ventilator.
Diagnostics and therapeutics were done,

FAMILY HISTORY
 Patient's parents are both alive and well. Father was 40 years old and Mother was 38 years old. No
family history of asthma, thyroid disease, malignancies, blood dyscrasias, PTB, twinning, congenital anomalies
and difficult labor.

IMMEDIATE NEONATAL PERIOD

APGAR SCORE
1 minute 5 minutes 10 minutes

Cardiac Over >100 2 Over 100 beats/ 2 Over 100 beats/ 2

Rate beats/ minute minute minute

Respirator Absent 0 Slow(irregular) 1 Slow (irregular) 1

y effort

Color Pink body, Blue 1 Body was pink 1 Pink Body, soles 2
extremities and palms

Response Grimace 1 Grimace 1 Grimace 1

to
Stimulatio
n

Muscle Limp 0 Some flexion 1 Some flexion 1

Tone

TOTAL 4 6 7

BALLARD’S SCORE
 Neuromuscular Maturity: ---
Physical Maturity: 20x2
Total: 20
Maturity Rating: 40 weeks age of gestation

PHYSICAL EXAMINATION at 12th hour of life

GENERAL APPEARANCE: Awake, fairly active
VITAL SIGNS:
CR: 120s bpm RR: assisted Temp: 36.8 C

ANTHROPOMETRIC MEASUREMENTS:
BW: 3.9 kg HC: 36 cm AC: 30 cm
BL: 48 cm CC: 33 cm

SKIN: Pinkish body, palms and soles, no jaundice, warm to touch

HEENT: Normocephalic, soft fontanels, anicteric sclera, no eye discharges; normal set ears, well curved pinna,
soft but ready recoil, no alar flaring, with no circumoral cyanosis, no cleft palate or lip
CHEST AND LUNGS: no retractions, no lagging, clear breath sounds, no crackles, good air entry
HEART: adynamic precordium, normal rate, regular rhythm, no murmurs
ABDOMEN: globular, non-distended, no bleeding or discharges in the umbilical stump, normoactive bowel
sounds, soft
GENITALIA: grossly Female, labia majora large, minora small
ANUS: Patent
EXTREMITIES: symmetrical, complete set of digits, no club foot with pinkish nail beds, creases seen over entire
sole, capillary refill time of 1 to 2 seconds. Barlow’s and Ortolani’s tests: negative
.
Course in the wards
On the 24th hour of life patient cycling movement of lower extremities and lip smacking. Patient was
given diazepam, serum electrolytes (Na, K, Cl) and ionized calcium, hgt, cranial UTZ were requested.

LABORATORY RESULTS:

CBC
Hgb 145
Hct 0.39
WBC 15.40
Neut 0.27
Lymp 0.77
Plt 250

Hgt: 100mg/dl

ABGs (1hr post mech vent)

pH 7.29
PO2 80mmHg
PCO2 55 mmHg
HCO3 15 meq/L

Blood typing: A+

Serum electrolytes
Na: 140 mmol/L
K: 3.6 mmol/L
Cl: 100mmol/L
Ionized Ca: 4.5mg/dl

Cranial UTZ: Unremarkable Findings