Clerk Hannah Lea David

December 10, 2010

Date of birth: December 9, 2010 Time of birth: 3:14 am

• Born to a 27 y/o G1P0 housewife, married to a 32y/o OFW

• Regular prenatal check-up since 2 mos. AOG ▫ Holy Clinic Navotas– 2 mos. AOG▫ Fabella Hospital (3 visits)- 7 mos AOG▫ USTH- 8 mos AOG▫ Total of >10 visits

• Regular intake of multivitamins and ferrous sulfate

• Denies exposure to viral exanthems, radiation

• Denies intake of illicit / regulated / prohibited / abortifacient drugs

• Non smoker, denies alcohol intake during pregnancy

Labs & Ancillaries:Hep B screening: HBsAg reactiveRPR: Non reactiveOGCT: normalCBC, U/A: NormalLast UTZ done 11/12: Single, live,

intrauterine pregnancy about 34 weeks & 4 days, BPS 8/8, EFW 2586+/- 387g

LMP: March 21, 2010, AOG: 37-38weeks (+) Mixed vaginosis- Metronidazole

suppository x 7 days at 8 months AOG (+) Hepatitis B diagnosed 2003 No history of hypertension, DM, thyroid

disorder, preterm labor

No hx of hypertension, DM, Cardiovascular diseases, thyroid disorder, PTB, hepatitis

10:30 AM BP 140/100 130/100 LAT: BFHR 150-160 bpm, good variability, (+)

accelerations (-) decelerations 12 MN- BP 120/80

BFHR 140-150 bpm Good variability, (+) acceleartions (-) decelerations

thinly stained amniotic fluid 2:30 AM- BP 120/80

BFHR 140-150 bpm, good variability with accelerations, no deceleration.

Live, term, singleton, male via NSD BW 2.98 kg, BL 50 cm, HC 32 cm, CC

30.5 AC 27cm APGAR Score 8, 9 MT 38-39 weeks AOG AGA

• VS: HR 154 bpm, RR 61, T: 36.8oC• BW 2.98 kg, BL 50 cm, HC 32 cm, CC 30.5

cm, AC 27cm• Active, good cry, good muscle tone,

acrocyanotic• (+) Mongolian spots• (+) caput succedaneum, (+) molding, no

cephalhematoma, patent, flat anterior fontanel

• (+) ROR, no eye discharge, no anomalies, normal set ears, no preauricular sinus, patent nares, no cleft lip and cleft palate

• Clavicle intact

• Symmetric chest expansion, no retractions, clear and equal breath sounds

• Adynamic precordium, rhythm regular, S1 and S2 normal, no murmurs

• Globular abdomen, umbillicus with 2 arteries and 1 vein, soft, no organomegaly, no masses

• Genitalia: bilaterally descended testes, good rugae

• Femoral pulses full and equal• (-) Barlow, (-) Ortholani• Spine normal curvature, no sacral dimpling, no

tufts of hair • no edema, no cyanosis• (+) moro, grasp, rooting, plantar, sucking,

swallowing reflexes

• Patient was dried and stimulated to cry• Cord clamping was done• Skin to skin contact• Latching done• Newborn care:

▫ Erythromycin eye ointment 1cm strip OU▫ Cord care with 70% ethanol▫ Vitamin K 1mg/IM▫ Hepatitis B vaccine, 0.5mL/IM on the

anterolateral thigh▫ Hepatitis B Ig 0.5 mL/IM

• Vital Signs monitored

• Bathing at 6th hour of life• Patient roomed in and exclusively

breastfed• For hearing screening on the 24th hour

of life• For newborn screening beyond 48th

hours of life

Total = 8

Total = 9

ASSESSMENT