Newborn Case Sheet

1. Identification

2. History of Present Illness

• Onset, duration and progression of each complaint.
• Feeding: breast or formula, frequency, sucking, vomiting (bilious or non-bilious), abdominal distension.
• Breathing: fast breathing, grunting, chest retractions, cyanosis, apnea.
• Activity: lethargy, irritability, convulsions, high-pitched cry.
• Temperature: fever or cold to touch.
• Jaundice: day of onset and extent of spread.
• Elimination: urine within 24 h, meconium within 48 h.
• Other: bleeding, umbilical discharge, skin pustules, eye discharge.
• Treatment already given and its response.

3. Antenatal History (Mother)

4. Natal (Birth) History

5. Postnatal History

• First feed: time and type. Was breastfeeding started within 1 hour?
• Skin-to-skin contact: done or not.
• Vitamin K given: dose and route.
• BCG, OPV-0 and Hepatitis B birth dose given.
• Cord care. Eye care.
• Passed urine (time) and meconium (time).
• Weight changes since birth.
• Any events: cyanosis, jaundice, convulsions, vomiting.

6. Family and Social History

• Family tree: parents' age, consanguinity, siblings (alive, dead, congenital anomalies).
• Family history of: metabolic disease, hearing loss, hemoglobinopathy, G6PD deficiency, neonatal jaundice in a sibling, early infant deaths.
• Socioeconomic status. Housing and sanitation. Who will care for the baby.

7. Examination

A. Anthropometry

• LBW <2500 g
• VLBW <1500 g
• ELBW <1000 g

• SGA <10th percentile
• AGA
• LGA >90th percentile

• Preterm <37 wk
• Term 37 to <42 wk
• Post-term ≥42 wk

• Dates (LMP or USG): ___ wk
• New Ballard score (most accurate at about 24 h): ___ wk

B. Vitals

C. General Examination

• Activity and cry: active / lethargic / irritable. Cry is normal, weak or high-pitched.
• Posture: flexed / extended.
• Color: pink / pale / cyanosed / jaundiced (Kramer's zones 1 to 5, Section 9).
• Skin: vernix, lanugo, milia, Mongolian spots, erythema toxicum, hemangioma, café-au-lait spots, petechiae, bruising, pustules, sclerema, edema.
• Dysmorphism: present / absent (describe).
• Hydration: fontanelle, skin turgor, mucosa.
• Pallor, icterus, cyanosis, clubbing, edema, lymph nodes.
• Hydration and nutrition: subcutaneous fat; look for wasting.

D. Systemic Examination

• Fontanelles and sutures: anterior fontanelle size and tension, posterior fontanelle, sutures (overriding or split).
• Scalp swellings: caput succedaneum, cephalhematoma, subgaleal hemorrhage.
• Face: facial asymmetry, palsy.
• Eyes: red reflex, cataract, coloboma, subconjunctival hemorrhage, discharge, squint.
• Ears: position, pits or tags, patency of the external canal.
• Nose: patent nares bilaterally (choanal atresia).
• Mouth: cleft lip or palate, high arched palate, natal teeth, tongue-tie, thrush, Epstein pearls.
• Neck: webbing, torticollis, cystic hygroma, clavicle fracture.

• Inspection: chest shape, symmetry, retractions, nasal flaring, grunting, stridor, apnea.
• Auscultation: air entry, crepitations, wheeze.
• Downes' score (record each item 0 to 2): ___ / 10. Items: respiratory rate, cyanosis, retractions, grunting, air entry.

• Apex beat. Heart sounds. Murmurs.
• Femoral pulses (compare with brachial). Radio-femoral delay.
• Four-limb BP if a cardiac lesion is suspected.
• Pre- and post-ductal SpO2 (critical CHD screening).

• Inspection and palpation: distension, tenderness, visible bowel loops.
• Organs: liver edge (normally 1 to 2 cm), spleen tip, kidneys, masses, bladder.
• Umbilical cord: two arteries and one vein; discharge, redness, granuloma, hernia, omphalocele, gastroschisis.
• Anus and inguinal region: anal patency, inguinal hernia.
• Bowel sounds.

• Male: testes in scrotum, hypospadias or epispadias, phimosis, hydrocele.
• Female: labia, clitoris, vaginal tags or discharge, imperforate hymen.
• Ambiguous genitalia: do not assign sex until investigated.
• Urine stream.

• Spine: sacral dimple, tuft of hair, meningomyelocele.
• Hips: Barlow and Ortolani tests. A systematic review of the infant hip exam was published in 2024 (JAMA, PMID 38619828).
• Limbs: club foot (CTEV), polydactyly, syndactyly, single palmar crease, limb deficiency, fractures.
• Brachial plexus: Erb's or Klumpke's palsy.
• Clavicles: crepitus, tenderness.

• Level of consciousness.
• Tone: normal, hypotonia, hypertonia.
• Posture: flexion or extension.
• Spontaneous movements.
• Primitive reflexes:

• Seizure activity. Cranial nerve signs. Cry quality.
• Bulging fontanelle.

E. Maturity and Neurological Assessment (New Ballard Score)

8. Other Screens

• Jaundice risk: bilirubin (transcutaneous or serum) plotted on hour-specific nomogram.
• Hearing screen (OAE / AABR).
• Newborn metabolic screen (TSH, G6PD, 17-OHP and others as per local program).
• Critical congenital heart disease screen (pulse oximetry).
• Eye red reflex.
• Hip stability.

9. Jaundice Assessment (if relevant)

• Kramer's zones:
  1. Face (about 5 to 7 mg/dL)
  2. Upper trunk (about 8 to 10)
  3. Lower trunk and thighs (about 11 to 13)
  4. Arms and legs below knees and elbows (about 14 to 16)
  5. Palms and soles (>15) These are approximate and are not a substitute for measuring bilirubin.
• Day of onset: before 24 h suggests hemolysis.
• Risk factors: ABO or Rh incompatibility, G6PD deficiency, prematurity, cephalhematoma, sepsis, poor feeding.
• Danger signs: lethargy, poor feeding, high-pitched cry, opisthotonos (bilirubin encephalopathy).
• Total serum bilirubin: ___ mg/dL (direct ___). Mother's and baby's blood groups. Coombs test.

10. Danger Signs Checklist

• Not feeding well or not able to suck
• Convulsions
• Respiratory rate >60 or <30, severe chest retractions, grunting, or apnea
• Temperature ≥37.5 °C or <35.5 °C
• Central cyanosis
• Lethargy or unconsciousness
• Bulging fontanelle
• Umbilical redness extending to skin or pus
• Many or severe skin pustules
• Jaundice in first 24 h or involving palms and soles
• Bilious vomiting or abdominal distension
• No urine in 24 h or no meconium in 48 h
• Weak or absent femoral pulses
• Bleeding

11. Summary of Case

12. Diagnosis

• Primary: e.g. term AGA neonate with early-onset sepsis / transient tachypnea of the newborn / hyperbilirubinemia.
• Associated problems:
• Differential diagnosis:

13. Investigations

14. Management Plan

1. Thermal care: skin-to-skin contact, kangaroo mother care, radiant warmer or incubator.
2. Respiratory support if needed: oxygen, CPAP, ventilation. Keep SpO2 within the target range for age and gestation.
3. Nutrition:
   • Exclusive breastfeeding on demand (8 to 12 times a day), or expressed milk or formula.
   • IV fluids if unable to feed: total fluid ___ mL/kg/day, Day 1 about 60 mL/kg, increase by 15 to 20 mL/kg/day to a maximum of about 150 mL/kg/day for term babies.
4. Glucose: maintain ≥45 to 50 mg/dL.
5. Antibiotics for suspected sepsis (drug, dose, duration).
6. Phototherapy / exchange transfusion per the bilirubin chart.
7. Seizures: treat per protocol (phenobarbitone and others).
8. Prophylaxis: vitamin K 1 mg IM (0.5 mg if under 1.5 kg), cord care, eye care.
9. Immunization: BCG, OPV-0, Hepatitis B birth dose.
10. Monitoring: vitals every ___ h, weight daily, intake and output.
11. Referral or escalation criteria.

15. Progress Notes

16. Discharge Summary

• Final diagnosis:
• Discharge weight and feeding:
• Discharge criteria: feeding well, stable temperature, weight loss <10% of birth weight and gaining, stable vitals, jaundice assessed, screens done, vaccines given, mother trained.
• Medications at discharge:
• Follow-up: within 48 to 72 hours of discharge, then per local schedule.
• Advice to parents:
  • Exclusive breastfeeding for 6 months.
  • Keep the baby warm and the cord clean and dry.
  • Hand hygiene.
  • Back sleeping.
  • Return urgently for any danger sign from Section 10.