ADMISSION NOTES -
SEEN AT NICU 0N _
...............
BABY OF _
DELIVERED VIA _
BROUGHT TO _
...................
MOTHER'S DETAILS
NAME:_
AGE: _ YEARS
ADDRESS: _
MARITAL STATUS: _
EDUCATIONAL STATUS: _
OCCUPATION: _
PARITY: NOW PARA _
BLOOD GROUP: _
HBSAG: _
SICKLING: _
G6PD: _
VDRL: _
RETRO- _
REPEAT RETRO- _
ANC VISITS: _
TT- _
IPT :_
__________________________
BABY'S DETAILS
DOB : _
MOD: _
GA: _
SEX: _
BWT: _
FL: _
HC: _
APGARS: _/10 AND _/10 AT 1 AND 5 MIN RESPECTIVELY
RESUSCITATION: _
COMPLICATIONS AT BIRTH: _
MECONIUM: _
URINE: _
EYE CARE: _
CORD CARE: _
VIT K: _
...............
VITALS ON ARRIVAL
SPO2- _
HR- _ BPM
T- _*C
RR- _CPM
WT- _KG
RBS: _MMOL/L
__________________________
ON EXAMINATION
A __ NEONATE, IN OBVIOUS RESPIRATORY DISTRESS (FAN, SCR ICR, XYPHOID RETRACTION), _FEBRILE, _ICTERIC, PALE- , __ HYDRATED, _ SPINAL DEFORMITY, EDEMA-, _CYANOSIS-,_ JAUNDICED,_ SCALP SWELLING
CVS: S1 + S2 + M0
RESP: AIR ENTRY IS ADEQUATE, BREATH SOUNDS ARE VESICULAR WITH NO ADDED SOUNDS
ABD: FULL , MOVES WITH RESPIRATION , NO PALPABLE ORGANOMEGALY ,UMBILICAL CORD _ AND _, NORMAL EXTERNAL GENITALIA OF THE MALE, APPROPRIATE FOR AGE
CNS; CONSCIOUS AND ALERT, NORMOTONIA IN ALL LIMBS, MORO PRESENT, GRASP +, SUCK PRESENT, FONTANELLE FLAT AND SOFT
..............
IMPRESSION
..............
PLAN + 2ND ON CALL
TO ADMIT
TO DO
IVF D10-
MONITOR VITALS
