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    Neonatal Case Sheet

    Uploaded by

    Johnsatish Rudrapogu
    This neonatal case sheet document contains sections to record maternal and family history, details of the present pregnancy and labour, natal history, postnatal period, symptoms noticed, physical examination including assessment of gestational age, classification of babies based on birth weight and gestational age, systemic examination, and space to record the final diagnosis. The case sheet is used to comprehensively document all relevant medical information for a newborn baby.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Neonatal Case Sheet

    Uploaded by

    Johnsatish Rudrapogu
    1K views18 pages
    This neonatal case sheet document contains sections to record maternal and family history, details of the present pregnancy and labour, natal history, postnatal period, symptoms noticed, physical examination including assessment of gestational age, classification of babies based on birth weight and gestational age, systemic examination, and space to record the final diagnosis. The case sheet is used to comprehensively document all relevant medical information for a newborn baby.

    Original Description:

    How to take history for a neonatal case

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    This neonatal case sheet document contains sections to record maternal and family history, details of the present pregnancy and labour, natal history, postnatal period, symptoms noticed, physical examination including assessment of gestational age, classification of babies based on birth weight and gestational age, systemic examination, and space to record the final diagnosis. The case sheet is used to comprehensively document all relevant medical information for a newborn baby.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    1K views18 pages

    Neonatal Case Sheet

    Uploaded by

    Johnsatish Rudrapogu
    This neonatal case sheet document contains sections to record maternal and family history, details of the present pregnancy and labour, natal history, postnatal period, symptoms noticed, physical examination including assessment of gestational age, classification of babies based on birth weight and gestational age, systemic examination, and space to record the final diagnosis. The case sheet is used to comprehensively document all relevant medical information for a newborn baby.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    NEONATAL CASE SHEET

    IAP UG Teaching slides 2015-16 1


    BASIC DATA
    • Baby of....... (Name of Mother) In Patient Number ________
    • Mother’s IP Number ___________________________
    • Name of Father _______________________________
    • Date and Time of Birth _________________________
    • Age (in seconds/minutes/hours/days as the case may be) 
    _________________________________________
    • Sex (male/ Female/ Ambiguous) __________________
    • Date and time of Admission _____________________
    • Address with Phone Number (important for follow up) 
    ____________________________________________
    IAP UG Teaching slides 2015-16 2
    MATERNAL/ FAMILY HISTORY

    • Age ______ years.  Blood Group _____ Rh type _____ Gravida 
    _____ Living children _____ Abortion _____

    • If abortion, which trimester? Any Known reason?

    • If any sibling deaths, at what age? Any known cause? Clinical 
    details?

    • Any other problem with previous children? (preterm delivery/ 
    developmental delay/ seizure disorder/congenital anomaly) If yes, 
    details?

    IAP UG Teaching slides 2015-16 3


    MATERNAL/ FAMILY HISTORY

    • Previous LSCS? If so, indication

    • Consanguinity? If yes, degree of consanguinity

    • Any medical Problem to mother

    • Any long term medications

    • Pedigree chart

    • Any significant medical problem in family

    IAP UG Teaching slides 2015-16 4


    PRESENT PREGNANCY
    • LMP......... Expected Date of Delivery.....

    • VDRL....HIV.....HBsAg.......Any other relevant tests

    • Periconceptional Folic Acid Yes/No

    • First Trimester‐ UTI/ vaginal bleeds/ any medication/ fever or/and rash/ 
    USG done/findings

    • Second Trimester‐ Fever and/or rash, PIH, USG, Medications, anaemia, 
    diabetes

    • Third Trimester‐ PIH/GDM/abnormal presentation/USG findings/ 
    medications

    IAP UG Teaching slides 2015-16 5


    LABOUR
    • Hospital/ Home/ any other place

    • Time taken for delivery after rupture of membranes

    • Any h/o foetal distress/ decreased foetal movements

    • Liquor‐ clear/ meconium stained/ foul smelling

    • Number of per vaginal examinations done after rupture of 
    membranes

    • Any fever just before or after delivery? If yes, any reason 
    known?

    • Mother on any antibiotics?
    IAP UG Teaching slides 2015-16 6
    LABOUR

    • Mode of Delivery – Normal/ Vaccume/ Forceps/ LSCS

    • Indication?

    • If LSCS, elective/ Emergency

    • Presentation 

    • Single/ multiple

    • Medications to mother‐ spinal/ Epidural/ General 
    anaesthesia, narcotics, any other
    IAP UG Teaching slides 2015-16 7
    NATAL HISTORY

    • Cried soon after delivery – Yes/ No

    • If not, details of resuscitation done and how baby responded to 
    that

    • Meconium staining of amniotic fluid

    • Whether handed over to relatives soon or admitted

    • Birth weight?

    • Apgar score at 1 minute/ 5minute/ 10 minute

    IAP UG Teaching slides 2015-16 8


    POST NATAL PERIOD
    • Any respiratory distress? If yes, details

    • Breast feeding initiated at what time? Sucked well? If not, details

    • Urine passed at what time? Stream?

    • Meconium passed at what time?

    • Any problem with temperature maintenance?

    • Whether noticed to have jaundice? If yes, at what hour of life? Severity? 
    How managed?

    • Any feeding problem?

    IAP UG Teaching slides 2015-16 9


    ANY SYMPTOM NOTICED?
    • Respiratory distress/ breathing difficulty/ apnoea

    • Feeding problem

    • Poor activity/poor feeding

    • Any seizure/ seizure like episodes?

    • Any congenital anomalies/ dysmorphism observed?

    • Any jaundice?

    • Any bleeding

    • Fever/ cold to touch

    • Abdominal distension/ constipation/ vomiting
    IAP UG Teaching slides 2015-16 10
    PHYSICAL EXAMINATION

    • General Appearance‐ whether looks sick or not?

    • Vital signs: Heart rate, Respiratory rate, Temperature, 
    Blood Pressure, Capillary Refill Time

    • Anthropometry: Weight, Length, Head circumference, 
    US:LS ratio,  Chest circumference

    • Weight gain adequate or not

    • Ponderal index or Dyne’s formula (to decide 
    symmetrical or asymmetrical)
    IAP UG Teaching slides 2015-16 11
    HEAD TO FOOT EXAMINATION

    • Head moulding/ fontanelle/ caput/ cephalhaematoma

    • Eyes‐ haemorrhage, red reflex, any abnormality

    • Ears‐ position, shape

    • Nose‐ abnormal shape, size, hypertelorism

    • Mouth: lips/ gums/ palate/ natal teeth

    • Neck: 

    • Skin: jaundice/ cyanosis/ rashes/ haemangioma
    IAP UG Teaching slides 2015-16 12
    PHYSICAL EXAMINATION

    • Umbilicus

    • Genitalia: testes descended/not, penis size, hypospadias, 
    ambiguity, pigmentation

    • Hernia/ hydrocele

    • Hip: DDH present/ No

    • Extremities 

    • Back and spine: myelomeningocele, spina bifida

    • Others 

    IAP UG Teaching slides 2015-16 13


    ASSESSMENT OF GESTATIONAL AGE

    • By Modified New Ballard Scoring system

    • Physical maturity and neurological maturity 
    assessed

    • Soon after birth or at least with in 72 hours

    IAP UG Teaching slides 2015-16 14


    CLASSIFICATION OF BABIES BASED ON BIRTH 
    WEIGHT AND GESTATIONAL AGE

    1. Term SGA
    2. Term AGA
    3. Term LGA
    4. Preterm SGA
    5. Preterm AGA
    6. Preterm LGA
    7. Post term SGA
    8. Post term AGA
    9. Post term LGA

    IAP UG Teaching slides 2015-16 15


    SYSTEMIC EXAMINATION 

    • Respiratory system

    • Cardiovascular system

    • Abdominal examination

    • Nervous system 

    • Neonatal reflexes

    • Musculo skeletal system 

    IAP UG Teaching slides 2015-16 16


    FINAL DIAGNOSIS

    • Gestational age‐ term/ preterm

    • AGA/LGA/SGA

    • Male/ female

    • Single/ first/second of twins

    • With specific diagnosis

    • Eg: 34 weeks preterm AGA, single male baby with neonatal 
    hyperbilirubinaemia, probably due to ABO incompatibility 

    • Suggest relevant investigations and management
    IAP UG Teaching slides 2015-16 17
    THANK YOU

    IAP UG Teaching slides 2015-16 18

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