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 reactive RPR: Non reactive OGCT: normal CBC, U/A: Normal Last 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 bpm, good variability, (+) accelerations (-) decelerations 12 MN- BP 120/80 BFHR bpm Good variability, (+) acceleartions (-) decelerations thinly stained amniotic fluid 2:30 AM- BP 120/80 BFHR 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 weeks AOG AGA VS: HR 154 bpm, RR 61, T: 36.8 o C 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 6 th hour of life Patient roomed in and exclusively breastfed For hearing screening on the 24 th hour of life For newborn screening beyond 48 th hours of life Total = 8 Total = 9 ASSESSMENT