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NICU Progress Note for Newborn Care

This document summarizes the admission note and progress note for a 12 hour old, term newborn male. At admission, the newborn was noted to have an erythema toxicum rash, right parietal cephalohematoma, and the mother reported sore nipples with feeding. On the second day of life, the newborn was feeding better, had mild jaundice, unchanged cephalohematoma, and a total bilirubin of 6.5 which was in the low risk zone. The plan was to follow the jaundice clinically and consider repeating the total bilirubin in the morning if the exam worsened.

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Haji Jawaro
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188 views3 pages

NICU Progress Note for Newborn Care

This document summarizes the admission note and progress note for a 12 hour old, term newborn male. At admission, the newborn was noted to have an erythema toxicum rash, right parietal cephalohematoma, and the mother reported sore nipples with feeding. On the second day of life, the newborn was feeding better, had mild jaundice, unchanged cephalohematoma, and a total bilirubin of 6.5 which was in the low risk zone. The plan was to follow the jaundice clinically and consider repeating the total bilirubin in the morning if the exam worsened.

Uploaded by

Haji Jawaro
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
  • MS Admission Note
  • MS Progress Note

MS Admission Note

ID: 12 hour old term newborn

HPI: Baby Boy Brown was born at 39+3 weeks by NSVD to a 27yo G3P1011 mom with
prenatal labs O+, Ab screen -, HBsAg-, VDRL non-reactive, GC/CT - , HIV -,
PPD+/CXR-. Pregnancy was complicated by PIH, treated with Mag. ROM was 7 hours
prior to delivery with clear fluid. Delivery was complicated by tight nuchal cord, cut
before delivery. Apgars 3 and 9. Baby received PPV for 30 seconds to improve color
and tone.

Baby has been doing well since birth, breastfed x3, stool x 1 and void x 1, VSS. Mom
states that feeding are going well, but she complains of sore nipples.

FH: sibling under bili lights for 2 days in newborn nursery, negative for congenital
diseases, childhood deaths, or atopic diseases.

SH: intact family, 3 yo sib; has all baby needs including car seat. Plans to receive care
at LPCH clinic.

PE: wt - 3578g, length - 49.5cm, OFC - 34cm, temp 36.7 - 37.1, HR 145 - 160, RR 48 -
52

gen - well appearing, NL tone/color/activity, crying with exam

skin - no jaundice, + red macules with central papules scattered on chest and legs

HEENT- normocephalic, + fluctuent area over R parietal bone, does not cross sutures,
+ RR B eyes, ears NL set/shape, palate intact, tongue WNL

neck - WNL, clavicles intact B

lungs - clear B, - G/F/R

CV - RRR without m, pulses +2 B

abd - soft, non-distended, liver palpable 2 cm below RCM, umbilical stump


intact/clamped

genitalia - NL male with testes descended B, anus patent

ext - hips stable B, all WNL

neuro- NL suck, grasp, Moro reflexes, DTRs +2 B


A/P: Term AGA newborn with low first apgar, with erythema toxicum rash and R parietal
cephalohematoma. Mom with soreness during feeds.

Expect spontaneous resolution of rash within 1 -2 weeks

Expect spontaneous resolution of cephalohematoma, but follow clinically for jaundice,


TBili to be drawn at 24 hours of life with newborn screen.

Discussed with mom expectations for feedings, RN to help with latch technique and
position, recommended BF class.

Susan Student, MS 3, pager 19790

CoSignature of MD

2/9/08 08:15

MS Progress Note

ID: Term AGA male, DOL #2

S: baby did well O/N, mom reports much less pain with feedings

O: VSS, BF x 11, void x 2, stool x 5 (mec), TB at 26 hours of life - 6.5, algo was passed
B

PE: wt - 3408g (down 5% from BW)

gen - well appearing, NL tone/color/activity, awake and alert

skin - mild facial jaundice, + red macules with central papules scattered on chest, abd,
and legs

HEENT- normocephalic, + fluctuent area over R parietal bone unchanged from yest, +
RR B eyes, ears NL set/shape, palate intact, tongue WNL

neck - WNL, clavicles intact B

lungs - clear B, - G/F/R

CV - RRR without m, pulses +2 B

abd - soft, non-distended, liver palpable 2 cm below RCM, umbilical stump intact/dried
genitalia - NL male with testes descended B, anus patent

ext - hips stable B, all WNL

neuro- NL suck, grasp, Moro reflexes, DTRs +2 B

A/P: Term AGA male, DOL #2, now feeding better, with mild
jaundice/cephalohematoma and TBili low int. risk on Bhutani graph.

Follow jaundice clinically, consider repeat TB in am if exam worsening.

Routine care.

MS Admission Note ID: 12 hour old term newborn HPI: Baby Boy Brown was born at 39+3 weeks by NSVD to a 27yo G3P1011 mom with
A/P: Term AGA newborn with low first apgar, with erythema toxicum rash and R parietal cephalohematoma. Mom with soreness duri
genitalia - NL male with testes descended B, anus patent ext - hips stable B, all WNL neuro- NL suck, grasp, Moro reflexes, D

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