SCN Clerking

AM REVIEW

*AM REVIEW must be complete and up to date with the progress*

B/O NORA / 32 HOURS OF LIFE (if more than 72 hours, just put how many days of life)

• DOB: 1/8/2019 @ 3.30AM
• SVD @ 39 weeks 2 days (if EMLSCS or ELLSCS, also state the reason – for suspicious CTG)
• BW: 3.2 kg
• CW: 3.0 kg (reduce 6.25%) – its normal for the baby to reduce in weight by 10-15% for the first 7-10 days then they will gain weight again. so if the weight reduce from 3.2 to 2.9 then up again to 3.0, dont state reduce. instead state increase using the difference between 2.9 and 3.0.
• Apgar Score: 9/9
• Liquor: clear/MMSL/LMSL
• G6PD: normal or deficient – (only discharge baby if result of G6PD came out normal. if deficient, admit baby for 5 days for observation)
• CTSH: normal is less than 21mIU/L

1. mother / 25 years old/ Para 2
2. Mother Blood Group – (if O+ve – think of ABO incompatibility in baby with jaundice onset less than 24 hours)
3. HIV/VDRL: Nonreactive
4. ANC:
   1. GBS Carrier (find out more about the risk)
      • low risk – mother received IV C-penicillin 2 doses more than 4 hours prior to delivery
      • moderate risk – mother received only 1 doses of IV C-penicillin less than 4 hours prior to delivery
      • high risk – no antibiotic given
      • any maternal risk- maternal pyrexia-maternal UTI
      • ARM for how many hours prior to delivery. PROM more than 18 hours is a risk factor for sepsis
   2. GDM on insulin
      • total insulin : 74 unit
      • latest HbA1c: 5.4% ( important to find out the glucose control. if uncontrol, baby had more risk of having hypoglycemia)
   3. Single Parent
      • was referred to JKSP
      • if underage- referred to Pelindung, but still under JKSP
   4. any other social issue

Issue:

1. Neonatal Jaundice
   • noted at how many hours of life.
   • noted by whom. JM visiting?
   • any TSB taken, Reticulocyte count
   • TSB @ 23 HOL : 234 (PL, ET)
   • TSB trend. take note of any respecification of the risk
   • feeding history:
     • exclusive breastfeeding / mixed feeding if breastfeeding – how long each session, whats the frequency (sustained 30mins – 45 mins each session, every 2-3 hours)
     • good latching, good letdown, good suckling
     • if mixed feeding – type of formula, dilution- how many scoop for how many ounces, frequency and amount
     • no traditional medicine or goats milk consumption
2. Infant of GDM mother on insulin
   • any jittery. any hypoglycemic symptom
   • reflo stable or not. less than 3 not stable
3. Failure to thrive
4. Infant of GBS carrier mother
   • on IV C-penicillin Day 2 and IV gentamicin Day 3 – to complete for 72 hours (must state abx on what day)
   • any sign of sepsis
   • TWC, Plt
   • Blood C+S

Progress/Currently:

• tolerating feeding well
• saturating well under room air
• HR BP stable
• Temp stable
• PU BO normal
• under single/double phototherapy

o/e: active, anterior fontanelle normotensive (AFNT), not tachypneic, CRT<2s, warm peripheries, good pulse volume,

• lungs: clear
• CVS: S1S2
• PA: soft, not distended

Investigation

• if on double photo, take TSB 4 hourly. if single photo, only take coming morning
• if NNJ < 4 hours, suspect ABO. take ABO workup. BBG, FBC, Retics, Coombs
• if presumed sepsis, take blood C+S
• if on gentamicin, take renal profile post genta

Plan

• Feeding – if on single photo – topup 10%. if double photo- topup 20%
• For single/double photo
• encourage breastfeeding on demand
• IV C-penicillin 100, 000 unit/kg/doses
• IV Gentamicin 5mg/kg/doses