PSOAP Neonatal Case Study Summary
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ScribdTranslationsPSOAP Neonatal Case Study Summary
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P...PRESENTATION
S...SUBJECTIVE
O...OBJECTIVE
A...ANALYSIS
P…PLAN
PRESENTATION
PATIENT WITH X YEARS OF AGE, WITH A HISTORY OF X, IS IN HIS/HER X DAY
INTRA-HOSPITAL STAY WITH DIAGNOSIS OF X.
DEPENDING ON THE CONDITION, CONSIDER PUTTING… AHF, APNP, APP,
GYNECOLOGICAL OR ANDROLOGICAL
SUBJECTIVE
WHAT THE PX REFERS TO (CURRENT DISORDER)….start, chronology,
companions, description of each one (relation to something, similar in the
past, sudden or gradual, duration, localization, characteristics, radiates, exacerbates
relief, treatments+evolution.
INTERROGATION BY DEVICES AND SYSTEMS IF NECESSARY AND WITH
SUSPECT
OBJECTIVE
Signos vitales: T, TALLA, PESO, TA, FC, FR
Physical examination: Patient in poor muscle-nutritional condition, with pallor
mucocutaneous generalizada,Orientado in 3 spheres, normocephalic
scleral icterus, pupils are normoreactive to light a the light,
moist mucous membranes, oral cavity without lesions, mobile cervical symmetry, no masses or
adenomegalies. Thorax symmetrical, expandable, without retractions, RsCsRs without murmurs.
universal vesicular murmur, no pulmonary overaggregates. Abdomen
positive peristalsis, soft depressible plane not painful no masses megalias
signs of peritoneal irritation upon palpation.
ANALYSIS
REASONING OF THE PATIENT'S CONDITION
PLAN
HOSPITALIZAR, DIETA, LIQUIDOS, MEDICAMENTOS, PARACLINICOS, CUIDADOS
OF THE CHILD, VITAL SIGNS AND NOTIFY CHANGES.
STORY OF A NEWBORN IN A SHARED LODGING ROOM.
NEONATOLOGY
Fecha: 16/11/14 Hora: 14:00
Identificación: Recién nacido hijo de Tatiana Vélez Gómez. C.C.: 39’420.090
Shared accommodation room
Mother of 32 years old, primipara G1V1A0P1C0, gestation
planned, newly born expected and longed for by married and resident parents
from Sabaneta, father lawyer and mother businesswoman, the mother attended 9 check-ups.
prenatal and underwent 3 gestational ultrasounds that did not detect any findings
abnormal. Amniotic fluid in normal quantity and appearance, non-reactive VDRL from
On 11/15/14, AgsHB and HIV negative from 11/15/14. Maternal blood type
and paternal O+. Delivered at 38 weeks vaginally in spontaneous vertex with amniotic fluid rupture.
epidural conductive anesthesia was used. Newborn of 15 hours old with
APGAR 8, 9, 10, no perinatal infections, TSH 5.0; Vaccinated with Hepatitis B and
BCG; tolerates oral route with breast milk; feces and urine +.
O/:Peso 3000 gr, Talla 50 cm, PC 33 cm, PT 32 cm, [Link] 30 cm, saturación 98%
newborn male alert, in good condition without extra oxygen.
general, suitable color and spontaneous activity.
Head: normocephalic, symmetrical, adequate hair implantation; fundus of the eye
normal; adequate implantation of the auricular pavilion, external auditory canal
permeable and intact tympanic membrane with a pearly color; intact palate, without
braces or natal teeth.
Chest: normally expandable, symmetrical, rhythmic heart sounds and no murmurs; without
respiratory difficulty, normal vesicular murmur without overlays.
- Abdomen: soft and depressible without enlargement or masses; healthy navel: 2 arteries and 1
vein, without signs of local infection.
-Pelvis and hip: femoral pulses present; male genitals
normoconfigured with descended testicles and permeable anus. Barlow and Ortolani
negatives.
Symmetrical extremities with preserved movements.
Yellowish skin, healthy, pink, capillary filling < 3 seconds.
Neurological: active, normal tone without abnormal postures, reactive with reflexes of:
search, suction, palmo-plantar grasp, Moro, galant, and patellar present.
A term newborn with appropriate weight for gestational age, without
biological or socio-family risk. Meets the four discharge criteria: no jaundice;
maternal, paternal, and neonatal blood typing 0+; with meconium and urine + and good
tolerance to enteral feeding with breast milk; without maternal or neonatal infection,
RN without clinical signs of congenital heart disease and with saturation above 95%,
The vaccination scheme has started. TSH 5.0.
P/: Medical orders: .
Registration with the following items:
Exclusive breastfeeding every 2 hours alternating breasts in each episode.
Childcare and warning signs for the prevention of sudden death.
Umbilical care without applying alcohol and encouraging skin-to-skin contact.
Enrollment in the growth and development program.
Review at 48 hours by outpatient consultation from primary level IPS.