History Taking in NICU - For RMO

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Presentation Description

Proper method of noting History with all required details for a newborn child

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History Taking in NICU Importance & Skills:

History Taking in NICU Importance & Skills Dr Manan Parikh

History Taking:

History Taking Ask Listen Document

Principles of History Taking:

Principles of History Taking Don’t be judgmental Ask clearly Listen carefully Don’t advise Check all written records thoroughly Co-relate in Doubt Document all points Be jolly and sympathetic

Components of Newborn History:

Components of Newborn History Clerical Data Maternal Details Labour Details Transfer Details Clinical Course before Admission Admission Details

Clerical Data:

Clerical Data Name: Indoor No. Male / Female Age: Date of Birth : Referring Doctor: Date of Admission : Attending Doctor: Weight on Admission: Obstetrician : Age: HOL / DOL Consanguinity Family History

Maternal Details:

Maternal Details Maternal Age: G P A L LMP: EDD: Mother Blood Group: Conception: Spontaneous / IVF Antenatal Risk Factors: Bleeding PV/ Leaking / Eclampsia / Decreased fetal movt / Poly – Oligo / Fever / Rash Maternal illness: Diabetes / Hypertension / Thyroid Dz / Other Systemic illness Maternal Medication Significant Antenatal USG Details Significant Fetal Details: FHS / NST / CTG Antenatal Steroid Yes / No Full / Incomplete Dexa / Beta PROM Yes / No Duration: Antibiotic Given / not

Maternal Details:

Maternal Details Maternal Age: <20 / > 30, Chromosomal GPAL: Gravida – No of times woman is Pregnant Para – No of times woman has delivered Abortion – No of abortion Live Child Conception Spontaneous IVF – More chances of Twins / Cong anomalies

Maternal Details:

Maternal Details Dates LMP EDD: LMP + 7 days + 9 months (40 weeks) Mother Blood Group O Positive Rh Negative ----- Anti D, Abortion, D&C

Maternal Details:

Maternal Details Antenatal Risk Factors: Bleeding PV --- Anemia, Infection Leaking PV --- Infection Eclampsia --- IUGR, MgSO4 --- Convulsion Decreased fetal movt --- Fetal Stress Polyhydramnios --- TEF, GI Obstruction Oligohydramnios --- PUV, Renal Dz, Pulmonary HP Fever --- Infection Rash --- Infection, Torch

Maternal Details:

Maternal Details Maternal illness: Diabetes – Hypogycemia , LFD, Hypocalcemia, Intestinal obstruction Hypertension – IUGR, Renal issues Thyroid Dz Other Systemic illness

Maternal Details:

Maternal Details Maternal Medication Significant Antenatal USG Details Significant Fetal Details: FHS / NST / CTG

Maternal Details:

Maternal Details Antenatal Steroid Betamethasone/ 12 mg IM/ 2 Dz/ 24 hrs apart Dexamethasone / 6 mg IM/ 4 dz / 12 hrs apart Antenatal Steroid Details Yes / No Full / Incomplete Dexa / Beta

Maternal Details:

Maternal Details PROM Premature rupture of membrane > 12 hrs before delivery PPROM Preterm Premature rupture of membrane High chances of Infection

Labour Details:

Labour Details Date of Birth: Time of Birth: Birth Weight: Mode of Delivery: NVD / Forcep / Vaccum / LSCS Vitamin K: Given / Not Given Indication for LSCS / Assisted Delivery Breech / Vertex Liquor: Clear / Meconium Stained Cried Immediately After Birth: Yes / No Resuscitation Details: APGAR 1 min 5 min 10 min Suction: Done / Not Done Urine: Passed / Not Passed Stomach Wash: Done / Not Done Stool: Passed / Not Passed Congenital Anomaly

Labour Details:

Labour Details Date of Birth / Time of Birth Birth Weight < 2.5 kg: LBW – Low Birth Weight < 1.5 kg: VLBW – Very Low Birth Weight < 1 kg: ELBW – Extremely Low Birth Weight

Labour Details:

Labour Details Mode of Delivery Normal Vaginal Delivery Assisted: Forceps / Vacuum / LSCS Reason for Assisted Delivery PROM Fetal Distress Meconium Pre- eclampsia Obstructed Labour Breech Previous LSCS

Labour Details:

Labour Details Presentation Vertex Breech Dysplastic Hip Shoulder dislocation Transverse Erb’s Palsy Traumatic Delivery

Labour Details:

Labour Details Liquor: Clear / Meconium Stained – Th / Tn Vitamin K: Given / Not Given Suction: Done / Not Done Urine: Passed / Not Passed Stomach Wash: Done / Not Done Stool: Passed / Not Passed Visible Congenital Anomaly @ Birth

Labour Details:

Labour Details Cried Immediately After Birth: Yes / No Resuscitation Details Bag & Mask / Intubation Endotracheal Suction Chest Compression Adrenaline / Medicines Cried @ ____ Min of Life

Transfer Details:

Transfer Details Transferred from Ambulance / Own Vehicle / Other Reason for Transfer Transferred on O 2 / Bag & Tube / T-Piece Medications

Clinical Course before Admission:

Clinical Course before Admission Condition of the baby Treatment given Working diagnosis Improvement / Deterioration Helps to Assess the severity of the illness Plan out our treatment accordingly

Admission Details:

Admission Details Weight: Head ©: Length: HR RR SpO 2 CRT Temp Peripheral Pulses Colour R/S CVS P/A CNS Umbilical Cord: 2A + 1V Genitals Cong. Anomalies Anal Opening

Gestational Age:

Gestational Age < 37 Weeks 37 – 42 Weeks > 42 weeks Preterm Full Term Post term < 28 Weeks 28 – 35 weeks 35 – 36 Weeks Extreme Preterm Preterm Near Term Late PT 37 – 40 weeks 40 – 42 Weeks Term Post Dated

Admission Details:

Admission Details Weight on Admission Loss / Gain from birth Charting on Fenton’s Growth Curve AFD / SFD / LFD Head © & Length IUGR – Symmetric / Asymmetric Microcephaly

IUGR / SFD:

IUGR / SFD RDS Hypoglycemia Hypothermia Polycythemia Jaundice HIGH Mortality

LFD:

LFD Associated with Maternal Diabetes Birth Trauma LSCS Hypoglycemia Hypocalcemia Polycythemia Jaundice Intestinal Obstruction Sacral Agenesis

Admission Details:

Admission Details Vitals Temp HR RR BP SpO2: On Oxygen / Bag & Mask CRT Peripheral Pulses Colour HGT SA Score Proper Units Site Special Findings

Admission Details:

Admission Details Cry Vigorous Cry is assuring Weak Cry: Sepsis, Asphyxia, Metabolic Hoarseness: Hypocalcemia, Airway injury High Pitch Cry: CNS Cause, Kernicterus Head Forcep Vaccum Marks Caput / Cephal

Admission Details:

Admission Details Abnormalities Show the parents & note properly Normal Variants Epstein Pearl Mongoloid Spot Erythema Toxicum

Admission Details:

Admission Details Respiratory Findings Mode of Oxygen Therapy RR Pattern Of Breathing SA Score Retraction Grunting Nasal Flaring Auscultation: Air Entry / Additional Sounds Nose & Upper Airway Ribcage

Admission Details:

Admission Details Cardiovascular System With / Without Support – Inotrpes Heart Rate Precordium Heart Sounds Murmur Cyanosis Peripheral Pulses BP with proper sized cuff Extremities

Admission Details:

Admission Details Per Abdomen Shape Distension Soft / Tense Organomegaly – Proper Note if present Umbilical Cord, Peri-umbilical Area Oral Cavity – Natal teeth, Tongue tie, Cleft Genitals Anal Opening

Admission Details:

Admission Details Central Nervous System Sensorium – Active, Drowsy, Depressed Pupil – Size, Equality, Reaction to light Movements – N / AbN, Convulsions Tone – Hypertonia / Hypotonia AF Head Circumference Shape of the Head, Sutures Spine & Back

Admission Details:

Admission Details Visible Congenital Anomaly 5 + 5 Fingers 5 + 5 Toes Openings: Nose / Mouth / Ears / Anal Head / Eye Limbs Shape

Newborn History:

Newborn History Ask Specifically Observe carefully Correlate Clinically Note neatly PUT YOUR IMPRESSION / WORKING DIGNOSIS

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