Question: HISTORY AND PHYSICAL EXAMINATION PATIENT: KAISER, Baby Boy MEDICAL RECORD NUMBER: 03-7843 DATE OF BIRTH: November 19, 20xx DATE OF ADMISSION TO NICU: November 19, 20xx HISTORY This Is A 3360 G, Full-term White Male Infant, Who Was Transferred From The Delivery Room To The NICU After Birth Because Of Respiratory Distress. The Infant Was Born To A 34-year-old …

HISTORY AND PHYSICAL EXAMINATION PATIENT: KAISER, Baby Boy MEDICAL RECORD NUMBER: 03-7843 DATE OF BIRTH: November 19, 20xx DATE OF ADMISSION TO NICU: November 19, 20xx HISTORY This is a 3360 g, full-term white male infant, who was transferred from the delivery room to the NICU after birth because of respiratory distress. The infant was born to a 34-year-old mother with an EDB of 11/22/xx, and he had an EGA of 40 weeks. MATERNAL HISTORY The mother was G2, PO with a SAB 2 years ago. The mother had prenatal care beginning in the first trimester of this pregnancy. She took prenatal vitamins. She denied the use of alcohol, smoking, or drugs. A sonogram on 10/10/xx showed a sin- gle fetus in breech presentation at 35 weeks’ gestation LABOR AND DELIVERY HISTORY The membranes ruptured spontaneously 14 hours prior to the onset of labor. The mother had a temperature of 103.2 degrees prior to delivery and was started on an antibiotic drug. A version of the breech was performed. Labor was induced and lasted 8 hours. The baby was born via normal spontaneous vaginal delivery. Apgars were 8 and 8 at 1 and 5 minutes respectively. There was no evidence of meconium aspiration on visual- ization of the vocal cords. The infant was tachypneic despite suctioning and the admin- istration of blow-by oxygen and was brought to the neonatal intensive care unit. PHYSICAL EXAMINATION Heart rate 200 beats/minute, respiratory rate 70/minute, temperature 101.2, weight 3360 g, length 54 cm, head circumference 33.5 cm. General: Full-term, AGA male. Alert, active, responsive. Head: Molding present. Fontanels soft. Palate intact. Eyes: Pupils equal and reactive to light. Chest symmetrical. Now pink in room air with only mild tachypnea and mild sternal retractions. Breath sounds equal bilaterally. Clavicles intact. Abdomen: Bowel sounds present. No hepatosplenomegaly. There is a 3-vessel umbilical cord. Genitalla normal. Anus patent. Neurologic: Strong cry, strong suck, nor- mal muscle tone. IMPRESSION Term male infant, estimated gestational age of 38.5 weeks, appropriate for gestational age. Aule out pneumonia. PLAN Admit to the neonatal intensive care unit. Vital signs q.1h. until stable. Cardiorespiratory monitor. Intravenous fluids of dextrose 10% in water at 80 cc/kg/day. Hold oral teedings for now. Vitamin K 1 mg IM. Chest x-ray to rule out pneumonia. 1. The sonogram on 10/10 showed what results? 2. What is the mother’s obstetrical history? 3. What abnormality of the head was noted on the physical examination? 4. What were the Apgar scores, and what do they signify? 5. Premature rupture of the membranes may lead to infection. What information is given that indicates this neonate did de dop an infection?