Newborn
Patient Case Number: NB08- Johnson, Tabitha
Patient Name: Tabitha Johnson | DOB: 10-05-XX | Sex: F
Date of Admission: 10-05-XX Date of Discharge: 10-07-XX | Physician: Dennis Harper, MD

# Discharge Diagnoses:

1. 41 2/7-week SGA delivered via Cesarean section 2/2 failure to progress

# Hospital Course:

The 41 2/7- week gestational age female was delivered via Cesarean Section and brought to the warmer. Spontaneous cry at delivery, resuscitation included tactile stimulation. Mother admitted with prolonged rupture of membranes. Trial of labor - failure to progress, repeat C/S Spinal anesthesia OB Complications: Premature rupture of membranes and prolonged rupture of membranes

# Physical Examination:

# Head: Anterior fontanelle is flat and soft. Eyes: No injection or discharge. Non-icteric. Ears: Ears normally set.

# Nose: No congestion or discharge.

# Throat: Palate intact. Mucus membranes moist.

# Neck: Supple.

# Heart: Regular rate and rhythm, no murmur, palpable femoral pulses, well perfused.

# Lungs: Clear to auscultation bilaterally No grunting.

# Chest: No retractions or deformity.

# Abd: Soft, non-tender, non-distended. No mass palpated. Cord has 3 Vessels.

# Genital: Female infant

# Rectal: Anus patent.

# Back: Straight. No deformity.

# Ext: No deformity. Spontaneous range of motion of all four extremities.

# Skin: No lesions. Pink.

# Neuro: Tone and reflexes appropriate for gestational age

# Exam is consistent with estimated Gestational Age: 41w2d.

# Comments: This is a 41 2/7 week-Small for Gestational Age female infant at risk for hypoglycemia secondary to SGA. Blood sugar monitoring per protocol. Maternal history of prolonged rupture of membranes, no reports for chorioamnionitis Infant to bond with family, routine care with PCP.

# Electronically Signed By: Dennis Harper, MD

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