Newborn Admit Note H&P

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CC: Newborn
HPI
Newborn baby _ born to a _ yo G_P_ at _ and _/_ weeks EGA who presented in _ labor with/without SROM at _/_/_. Total time with ruptured membranes was _.  She was (not) induced/augmented and progressed well to complete over about _ hours. Patient then began to push, and at this time of 2nd stage of labor had _ complications. She delivered a vigorous baby in _ position via vaginal delivery. There was _ nuchal cord reduced by _. Baby was immediately placed on mother’s abdomen and cord was clamped after _ minutes. Baby with _ cry and APGARS at 1 and 5 minutes of _ and _, respectively.
 
Maternal Prenatal Hx:
ABO/Rh: _
Antibody: _
Hgb: _
Pap: _
Rubella: _
Varicella: _
VDRL: _
Urine Cx: _
HBsAg: _
HIV: _
CT: _
NG: _
MSAFP: _
1 hr GTT: _
GBS: _
PPD: _ 
 
Pregnancy Complications: _
 
Pertinent Family History: _
 
Physical Exam
.vitals
.birthweight
 
GEN: NAD
HEENT: Red Reflex seen b/l, external ears w/o tags or pits, AFOF, + molding, No cephalohematoma, hard palate intact
NECK: Negative clavicular fx
CV: RRR, no MRG
RESP: CTAB, no distress
ABD: nl BS, soft, nd, no masses, no guarding
RECTAL: Patent, no masses
GU: Normal female genitalia for newborn, patent urethra and vagina
PULSES: 2+ femoral pulses b/l
EXTR: No swelling or edema in the BLE, No acrocyanosis, Negative Ortoloni and Barlo b/l
SKIN: No rashes or lesions thorughout body, no spinal tufts of hair or dimples, No Jaundice
NEURO: MAEE, good tone, +Morro, +Grip in all four extremities, +Galant b/l
 
Assessment and Plan:
DOL#_ for this _ and _/_ week EGA _ born via _ complicated by _ to a _ yo G_P_->_ mom who is _ (blood type) and Antibody _ with prenatal course that was complicated by _ and normal PNL except _ with adequate/inadequate intrapartum prophylaxis.
 
Maternal Blood type _: (Do not) send cord blood for HDN w/u
Breast Feed on demand with support as needed
Hepatitis B Vaccination: Give _
State NBS per routine, CHD screen per routine, Hearing Screen per routine
Routine couplet care otherwise.
Last modified on %PM, %023 %27 %2015 %16:%Apr
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