S HPI: Baby _____ ___________was born at _______weeks with APGARs ___and___s/p __________________________ (why_________________________________________) to a __yo G_P_______ with (blood

type_____), (Ab screen______),GBS________________________________________________(if positive pt requires a septic workup: did mom get amp?) HBsAg, HIV. ROM (amount of time) with what color fluids. _______________________________ Complications during delivery.___________________________________________________________________________ Problems feeding(formula)_______________________________________________________ O BP_________ HR___________ RR_____________ TEMP_________________________ WEIGHT(any loss)_____________ LENGTH___________________ OFC__________________________ -General: color, posture/tone, activity, size, maturity, and quality of cry. -Head: bruising, edema, molding/shape, sutures, and fontanelles. -Examine clavicles for range of motion, asymmetry, masses, or crepitus. Assess eyes for symmetry, set/shape, discharge, erythema, and red light reflex, jaundice. -ENT: ear set/shape, preauricular pits/tags, nasal shape/patency, palate, gums, lips, and tongue. Palate should be intact. -CHEST: shape of thorax, position of nipples, and work of breathing. -HEART/LUNGS: breath sounds, heart murmurs, and femoral pulses. -ABD/UMB: bowel sounds, liver, spleen, kidneys, and umbilical cord (should be clean and dry with three vessels). -GENITALIA: labia, hymen, penis, testicles, and anus. -TRUNK/SPINE: symmetry, skin lesions, and masses. -EXT: mobility, deformity, and stability, digits. -NEURO: suck, grasp (hands and feet), and Moro. -INTEG: jaundice, erythema toxicarum, Mongolian spots. -STOOLING PATTERN, URINE OUTPOUT, EATING, DRINKING!

LABS: CBC, BMP, CRP, BILI (TIME, TOTAL/DIRECT, and what risk according to chart), Septic Workup (CBC with diff ((must record bands)), CRP and BLOOD CULTURES 48HR), FINNEGAN Abstinence sheet for withdrawal.

A/P