Newborn Admission Note

[textarea columns=80 rows=50 default="HISTORY OF PRESENT ILLNESS:
#1 Newborn infant admission note
***Was present at/Was not present at/Called to*** the ***spontaneous vaginal/C-section/vacuum assisted vaginal/forceps assisted vaginal/precipitous vaginal*** delivery of this ***gestational age*** infant ***female/male*** to a ***mom’s age*** year old G*** P*** now P***. Mother’s blood type ***. Mother’s Rubella status ***RI/RNI/R unknown***, ***HBV-/HBV+/HBV unknown***, ***HIV-/HIV+/HIV unknown***, ***GBS-/GBS+/GBS unknown***
Pregnancy complications: ***uncomplicated/GBS positive/GBS Unknown/Hepatitis B surface antigen positive/< 37 weeks gestation/Meconium-stained amniotic fluid/PIH/Pre-eclampsia/Diabetes/Gestational diabetes/Multiple gestation/Breech presentation/Chorioamnionitis***
Delivery complications: ***Uncomplicated/Breech presentation/Chorioamnionitis/Failure to progress/Meconium/Non-reassuring fetal heart rate tracings/Nuchal cord/Shoulder dystocia***
Maternal medications prior to delivery included: ***Glyburide/opiods/betamethasone/antibiotics***
At birth, the infant ***gave spontaneous breaths, cried, and was warmed, dried, and stimulated/was resuscitated***. Resuscitation measures included: ***Bulb suctioning and tactile stimulation/Blow by oxygen for *** minutes/Positive pressure ventilation for *** minutes/Chest compressions for *** minutes/Intubation/IV fluids/medications***.
Apgar scores were *** at 1 minute, *** at 5 minutes.
Labs drawn: ***CBC/Blood culture/Blood gas ***pH, pCO2, pO2, HCO, base excess***/blood glucose
Imaging: ***Chest x-ray/Abdominal x-ray***
EXAMINATION:
Vitals: ***height/weight/head circumference/birth temperature***
Skin: Normal turgor and without lesions.
Head: Normocephalic with age appropriate fontanelles.
ENT: Palate is complete.
Eyes: Red reflex present bilaterally. Pupils equally round and reactive to light.
Lymph Nodes: No significant lymphadenopathy.
Thyroid: No thyromegaly; trachea midline without masses.
Breasts: Without lesions or drainage.
Peripheral Vessels: Normal pulses and perfusion.
Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs.
Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds.
Abdomen: Soft, without organomegaly. Bowel sounds normal. Nontender without rebound. No masses palpable. No distention.
Genitalia: ***Normal male external genitalia; testes descended bilaterally; no hernia./Normal female external genitalia.***
Tanner Stage: I.
Spine: Straight with no lesions.
Joints: Hips with full range-of-motion; negative Barlow and Ortolani.
Extremities: No clubbing, cyanosis, or edema. Normal upper and lower extremities.
Mental Status: Alert, oriented, in no distress. Appropriate for age.
Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age.
ASSESSMENT/PLAN:
#1 Newborn ***Premature/Term*** ***Female/Male***
-Admit to Newborn Nursery for routine newborn cares
-Hearing Screen, state newborn screen prior to discharge
-Hepatitis B vaccine per nursing protocol
-Feeds ad lib"]