Page 1 of 52 Record And Demographic Details...2017/12/18 · 11/27/2017 3:18pm Confidential Nairobi...

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ConfidentialNairobi Newborn Study: Neonatal Medical Record

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Record And Demographic Details

Unique ID __________________________________(Use format [hosp id][record id])

[hospital ID][data clerk ID][0001]

Hospital ID ABCD

Data entry person ID ABCD

Patient number (IP No.) __________________________________(e.g. 01)

Today's date __________________________________

*Obtain this information from the admission record*

Date of admission __________________________________((for empty date type 1915-01-01))

Date of birth __________________________________((for empty date type 1915-01-01))

Age documented? Yes No

Age less than 24 hours? Yes No

Age (days) __________________________________(Enter age in days.)

Sex Male Female Unknown/missing

Referred IN from another facility? Yes, from another facilityYes, from homeNo, inborn/not born before admission (BBA=no)Empty

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Where referred FROM? (Name of facility) Kenyatta national hospitalAga khan hospitalMbagathi District hospitalNairobi HospitalMama Lucy Kibaki hospitalNairobi west hospitalPumwani maternity HospitalThe Karen HospitalMater HospitalRadiant Pangani HospitalSt Francis Com HospitalMp Shah HospitalNairobi Women's Hospital (Hurlingham)Nairobi Women's Hospital (Adams)Alliance Medical CentreRuaraka Uhai Neema HospitalAvenue HospitalCoptic HospitalGertrudes children's HospitalGuru Nanak HospitalLangata HospitalMaria immaculate health centreMother and Child hospitalNairobi East HospitalNairobi South HospitalSkyhill Medical CentreAfwan Medical ClinicMeridian Equator HospitalMetropolitan HospitalSouth B Hospital LimitedFamily care medical centreKomarock Modern Medical CareMarura Nursing HomeSt Mary's Mission HospitalAl-Amin Nursing HomeLadnan HospitalEmpty

Facility referred from not on lookup list? Not on list

Specify facility not on lookup list __________________________________



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Residency: Location BahatiDandora

(this can be the location of the mother) Eastleigh northEastleigh southEmbakasiGithuraiHighridgeHurumaKabeteKahawaKamitiKamukunjiKangemiKarenKariobangiKariobangi southKariokorKasaraniKataniKawangwareKayoleKenyatta/golf courseKiambaaKiambaa s/areaKiberaKiharaKilimaniKinooKitenkelaKitisuruKoma rockKorogochoLaini sabaLangataLavingtonLukenyaMakadaraMakongeniMaringoMathareMugumoiniMukuru kwa njengaMukuru nyayoMutuiniNairobi westNgaraNgongNjiruNkaimoronyaNyathunaOlooluaOngata rongaiParklandsPumwaniRirutaRoysambuRuaiRuakaRuarakaRuiruSera ngombeSettled areaStareheUmojaUthiru/ruthimituViwandaWaithakaEmptyViwandani



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Location not on look up list? Not on list

Specify location not on look up list __________________________________



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Residency: Sub-location RuiruAnmer

(this can be the sub-location of the mother) KiuKahawa northGathangaThimbiguaRuakaMuchathaKahawa southRoysambuKaruraKoma rock, Koma rockKiharaRuaiGathigaKasaraniKibichikuLower kabeteMuthaigaKitisuruRuarakaKinooDandoraLoresho/kyunaKorogochoUthiruSp. Valley/u.parklandsKariobangi northHurumaHighridgeThogotoUmojaKariobangi southMathareUthiru/ruthimituMuthangariMihangoEastleigh northKangemiPanganiKileleshwaUhuruMasiwaNgara eastNgara westKawangwareKilimaniWaithakaNairobi centralHarambeeRirutaZiwani/starehe/kari'rEastleigh southMajengoCity squareMutuiniAthi riverLumumbaKimathiShauri moyo/kamukunjiMuthurwaEmbakasiOfafaNairobi southHamzaKaloleniKenyatta hosp.MakongeniKarenMbotela


Viwandani(ind. Area)Golf courseWoodleyNairobi westLangataKiberaMugumoiniEmptyKia maikoMabatiniMlango kubwaCity centreGatinaKiriguNgandoDandora ADandora BMowlemKayoleKomarockImara daimaUpper parklandsMukuru kwa njengaMaili sabaNjiruSavannahNgunduGithuraiKamuthiKahawa west/Juja KKiwanjaKongo sowetoMwikiGitathuruBaba dogoNyayoNyayo highriseGardenNjathainiMathare 4AMathare NorthUtaliiLenanaLindiMakinaSilangaLaini sabaHardyBomasSouth CGatwikiraOlympicOfafa maringoHazinaLandi maweAirbaseCaliforniaGikombaGorofani/BondeniGichagiMountain ViewMaziwaSpring Valley

Sub-location not on look up list? Not on list


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Specify sub-location not on look up list __________________________________




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History Taken At Admission

*Obtain this information from the clinical admission notes ONLY*

Gestation at birth (weeks) __________________________________(No. of whole weeks. If empty enter -1)

Is Apgar score documented? Yes No

Apgar 5 minute 012345678910Empty

Apgar 10 minute 012345678910Empty

Birth weight (in kg) __________________________________(in kilograms. Only enter in kg or g, not both. Ifempty enter -1)

Birth weight (in g) __________________________________(in grams. Only enter in kg or g, not both. Ifempty enter -1)

Admission weight (in kg) __________________________________(in kilograms. Only enter in kg or g, not both. Ifempty enter -1)

Admission weight (in g) __________________________________(in grams. Only enter in kg or g, not both. Ifempty enter -1)

Mode of delivery Spontaneous vaginal (SVD)Assisted vaginal (Includes Forceps,Vacuum)BreechCaesarean section (C/S)Empty



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Newborn resuscitation previously performed Yes No Not recorded/empty

HIV status

*check mother's details too*

Not exposed ExposedNot recorded/empty

Length of illness (days) __________________________________((Duration for longest presenting complaint, enter-1 if unrecorded))

Assessment

*Make sure that you enter information about HISTORY and not assessment*

Yes No Empty

Prolonged ROM (>18 hours)

Fever

Difficulty breathing

Diarrhoea

Severe vomiting (vomitseverything)

Difficulty feeding/breastfeeding

Convulsions

Partial/focal fits

Apnoea




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Examination At Admission


Vital signs

Temperature (degrees Celsius) __________________________________(in degrees celsius to one decimal place e.g. 37.0(enter -1 if empty))

Respiratory rate/Resp Rate/RR (per minute) __________________________________(indicate per minute (enter -1 if empty))

Pulse value/Heart rate/HR (per minute) __________________________________(indicate per minute (enter -1 if empty))

Oxygen saturation documented Yes No

Oxygen saturation (%) __________________________________

Airway and Breathing

Cry Normal Weak HoarseEmpty

Indrawing none/mild severesternum Empty

Breathing

Yes No Not recorded/empty

Stridor

Central Cyanosis

Grunting

Air entry bilateral

Crackles/crepitations

Circulation

Femoral pulse Normal Weak Empty



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Capillary Refill Time (CRT) X-indeterminate1 second or less2 seconds3 seconds4 seconds5 seconds6 seconds or moreNot recorded/empty

Murmur Yes No Empty

Pallor/Anaemia noneyes, but not classifiedyes, +(mild/moderate)yes, +++(severe)empty

Skin cold up to HandElbowShoulderNo coldEmpty

(Indicate all that apply)

Disability

Yes No Not recorded/empty

Can suck/breastfeed

Stiff neck

Bulging fontanelle

Irritable

Reduced movement/floppy

Umbilicus Clean Local pusPus + red skin Empty

General Examination

Skin appearance BruisingRashPustulesNormalEmpty

Jaundice (Yellowness of eyes) none(0)yes, but not classifiedyes, +(mild/moderate)yes, +++(severe)empty

Size for gestational age Normal SGA/wasted/smallLGA/large Empty



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Abnormalities SkullLimbs / spinePalate / faceGenitals / anusDysmorphicGastrointestinalOtherNoneEmpty

(check all that apply)

Other abnormality, please specify __________________________________

Skin pinch (seconds) 0 sec/immediate1-2 sec>2 secempty




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Investigations At Admission


Bilirubin test ordered Yes No

Lumbar puncture (LP) test ordered Yes No




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Admission Diagnoses


Clear primary admission diagnosis? Yes No Empty/No diagnosis(Select 'Empty' if no diagnosis is available)



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Primary admission diagnosis Accompanying other twinAKIAdmitted due to mother's conditionAdmitted for observationAlbinismBABirth traumaBrachial plexus InjuryBurnsCaput SuccedaneumCephalohaematomaCerebral palsyChest malformationCBBAChorioamnitisCleft palateCHDCTEVCystsDehydrationPoor feedingDIBDistended abdomenEONsEpispadiaErb's palsyExtra digit on handFacial oedemaFebrile convulsionsFrothingGastrointestinal bleedingGrunting respirationHaematomaHepatitisHypersecretionHypoglycaemiaHypospadiaHypothermiaHIEImperforate anusInfection exposureIURGneonatal jaundice,NNJJointed penisLeft eye medial strabismusLeg hyperextension in deliveryLipomaLALarge for gestational age,LGAMAMBACesarean section,CSMother has no breast milkMothers drug abuseNasal blockage/Blocked nostrilsNEC, NECNeonatal AnaemiaNeonatal convulsionsNMNNS,EONS,NNTNRDS,RDS, Respiratory Distress SyndromeParaphimosisPhimosisPneumoniaPneumonitis/pulmonitisPolycythemia VeraPoor apgar scorePostdatismPremature labour


LBWpretermPEMRenal failureRhesus incompatibilityRisk of sepsis /infectionScrotal swellingSeptic PustulesSeptic ShockSero-reactive mother/Sero exposedSevere Birth asphyxiaSTIShockShoulder dislocationShoulder dystociaSkin rashesSGASoft tissue injurySpina BifidaSpinal dysraphismSquintSwollen face due to pubis presentationSwollen foreheadThigh massTwin deliveryUmbilical herniaUndescended testes

Primary admission diagnosis not listed? Not on list

Specify primary admission diagnosis not listed __________________________________(Specify diagnosis)


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Admission diagnosis 1 Accompanying other twinAKIAdmitted due to mother's conditionAdmitted for observationAlbinismBABirth traumaBrachial plexus InjuryBurnsCaput SuccedaneumCephalohaematomaCerebral palsyChest malformationCBBAChorioamnitisCleft palateCHDCTEVCystsDehydrationPoor feedingDIBDistended abdomenEONsEpispadiaErb's palsyExtra digit on handFacial oedemaFebrile convulsionsFrothingGastrointestinal bleedingGrunting respirationHaematomaHepatitisHypersecretionHypoglycaemiaHypospadiaHypothermiaHIEImperforate anusInfection exposureIURGneonatal jaundice,NNJJointed penisLeft eye medial strabismusLeg hyperextension in deliveryLipomaLALarge for gestational age,LGAMAMBACesarean section,CSMother has no breast milkMothers drug abuseNasal blockage/Blocked nostrilsNEC, NECNeonatal AnaemiaNeonatal convulsionsNMNNS,EONS,NNTNRDS,RDS, Respiratory Distress SyndromeParaphimosisPhimosisPneumoniaPneumonitis/pulmonitisPolycythemia VeraPoor apgar scorePostdatismPremature labour



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Specify any other admission diagnoses __________________________________(Specify diagnoses, separating each by :)

Other admission diagnoses Yes No


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Other admission diagnosis 1 Accompanying other twinAKIAdmitted due to mother's conditionAdmitted for observationAlbinismBABirth traumaBrachial plexus InjuryBurnsCaput SuccedaneumCephalohaematomaCerebral palsyChest malformationCBBAChorioamnitisCleft palateCHDCTEVCystsDehydrationPoor feedingDIBDistended abdomenEONsEpispadiaErb's palsyExtra digit on handFacial oedemaFebrile convulsionsFrothingGastrointestinal bleedingGrunting respirationHaematomaHepatitisHypersecretionHypoglycaemiaHypospadiaHypothermiaHIEImperforate anusInfection exposureIURGneonatal jaundice,NNJJointed penisLeft eye medial strabismusLeg hyperextension in deliveryLipomaLALarge for gestational age,LGAMAMBACesarean section,CSMother has no breast milkMothers drug abuseNasal blockage/Blocked nostrilsNEC, NECNeonatal AnaemiaNeonatal convulsionsNMNNS,EONS,NNTNRDS,RDS, Respiratory Distress SyndromeParaphimosisPhimosisPneumoniaPneumonitis/pulmonitisPolycythemia VeraPoor apgar scorePostdatismPremature labour



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Other admission diagnosis 2 Accompanying other twinAKIAdmitted due to mother's conditionAdmitted for observationAlbinismBABirth traumaBrachial plexus InjuryBurnsCaput SuccedaneumCephalohaematomaCerebral palsyChest malformationCBBAChorioamnitisCleft palateCHDCTEVCystsDehydrationPoor feedingDIBDistended abdomenEONsEpispadiaErb's palsyExtra digit on handFacial oedemaFebrile convulsionsFrothingGastrointestinal bleedingGrunting respirationHaematomaHepatitisHypersecretionHypoglycaemiaHypospadiaHypothermiaHIEImperforate anusInfection exposureIURGneonatal jaundice,NNJJointed penisLeft eye medial strabismusLeg hyperextension in deliveryLipomaLALarge for gestational age,LGAMAMBACesarean section,CSMother has no breast milkMothers drug abuseNasal blockage/Blocked nostrilsNEC, NECNeonatal AnaemiaNeonatal convulsionsNMNNS,EONS,NNTNRDS,RDS, Respiratory Distress SyndromeParaphimosisPhimosisPneumoniaPneumonitis/pulmonitisPolycythemia VeraPoor apgar scorePostdatismPremature labour



Specify any other admission diagnoses __________________________________(Specify diagnoses, separating each by :)



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Drug Treatment Prescribed At Admission

*Obtain this information from the clinical admission notes/treatment sheet ONLY*

Is there a treatment sheet in the file? Yes No(CHECK AND ASCERTAIN BEFORE YOU SELECT "NO")

Antibiotics

Benzyl/Crystalline Penicillin(Xpen) prescribed? Yes No

Route I.M I.V empty

Dose __________________________________(Amount prescribed per dose (enter -1 if notrecorded))

Units of dose IU mg MU(megaunit)Empty

Frequency OD/once a day/24hrlyBD/twice a day/12hrlyTID/TDS/three times a day/8hrlyQID/4 times a day/6hrlySTATEmpty

Gentamicin prescribed? Yes No

Route I.M I.V empty

Dose __________________________________((enter -1 if not recorded))

Units of dose mg Empty

Frequency Once per day/once daily(OD)12 hourly8 hourly6 hourlyEmpty

Additional treatment

Additional drugs prescribed during admission Yes No



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Other drugs 1 AdolAla-scalpAlbendazoleAlbenzaAldometAmiferAmikacinAmikinAminophylineAmodiaquineAmoxicillin/Clavulanate potassiumAmpicillin/CloxacillinAmpiclo dawaAmpicloxAntiseptic BathsArtemether/lumefantrineAugmentinAxylinBactrimBactroban creamBestumBrufenCalpolCandid B mouthwashCeftazidimeChlorphenamineCincifranCiproCiprofloxacinCoartemComaquinCortril ointmentCortrimazoleCotrimoxazoleCough syrupDawafloxDawastinDecadronDesenexDexamethasoneDexasoneDiastatDiazepamDiodexEfferalganEpigardEpinilErgamisoleErythrocinErythromycinFefolFlagylFlavoquinFloxapenFlucloxFlucloxacillinFolateFolic acidFortumFracloxFungistinFurosemideFusidGabapentinGabatinGabixHexadrolHydrocortisone creamIbuprofenIron supplements


KacinKeftazLanomycinLasixLefrusidLevamisoleLotriminMetacyclineMethyldopaMetronidazoleMicort-HCMixavit syrupMultivitaminsMupirocin creamMycostatinNeotackNeurontinNevimuneNevirNevirapineNevivirNo Rash creamNorphylNutracortNycostatNystatin suspensionPanadolParacetamolPediamycinPedsolPhenetronPhenobarbPhenobarbitalPhylocontinPiritonPrednisonePrednizenQualaquinQuinineRanferonRanitidineReducidSalbutamolSaline nasal drops

Solvazinc, SolvazincSulbutSulfatrimTazidTerramycineTetracycline eye ointmentTrivagizoleTruphyllineUltacValiumVentolinViramuneVitamin B9Vitamin KZantacZeefeeZinc oxideZinc sulphateZincate, Zincate


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Other additional drugs, please specify __________________________________(Specify drugs, separating each by :)

Receiving ARV prophylaxis? Yes No Not recorded/empty

*Checking the whole file*

Diazepam prescribed at any time during inpatientcare?

Yes No




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Supportive Care Prescribed At Admission

Oxygen prescribed at admission for first 24 hours

Oxygen ordered? Yes No

Route of oxygen administration Nasal CatheterNasal prongsNasal (with no indication of type)Simple maskMask with a reservoirOtherNot recorded/empty

Feeds prescribed at admission for first 24 hours

Feeds prescribed at admission? Yes No

Type of feeds prescribed Expressed Breast Milk (EBM)Neonatal formulaCow's milkMixed feedingOtherEmpty

Time to start feeds (after admission) < 1 hr1-2 hrs>2hrsEmpty

Feeding route prescribed Nasogastric tubeCup and spoonOtherEmpty

Feed Volume (ml) __________________________________(total volume in mls per feed (enter -1 if empty))

Frequency of administration hrly2hrly3hrly4hrly5hrly6hrlyEmpty

Duration of feed prescribed (hours) __________________________________((enter -1 if empty))



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Fluids prescribed at admission for first 24 hours

Fluids prescribed at admission using intravenous(I.V) route?

Yes No

IV fluids prescribed Half strength darrows(HSD)Half strength darrows with 5% DW10% DW(D10W)Normal Saline(NS)Ringers Lactate/Hartmanns(RL)5% DW(D5W)OtherEmpty

Volume of IV fluids (ml) __________________________________((enter -1 if empty))




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Follow Up Monitoring

*Clinical review AFTER admission (look through the entire file for this information)*

Evidence of further clinical review Yes No

Date of first clinical review after admission __________________________________(if empty enter 1915-01-01)

MONITORING

Vital signs chart present and filled? Yes No

Number of days for which vital signs chart is filled __________________________________((days))

Vital signs monitored in the first 48 hours afteradmission?

Yes No

Number of times temperature recorded in the first 48 0hours after admission 1

2345678910>10Empty

((If length of stay was less than 48 hours, notetotal number of times temperature was recorded))

Number of times respiratory rate recorded in first 48 1hours of admission 2

345678910>10Empty

((If length of stay was less than 48 hours, notetotal number of times respiratory rate wasrecorded))



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Number of times heart rate recorded in first 48 hours 1of 2admission 3

45678910>10Empty

((If length of stay was less than 48 hours, notetotal number of times heart rate was recorded))

Feeding monitoring chart available and filled? Yes No

Duration for which feeding chart is filled (hours) __________________________________((hours))

Number of times feeding recorded as given during the 1period of monitoring (i.e. timeframe above) 2

345678910>10Empty

Fluid chart available with evidence of monitoring? Yes No

Duration for which fluid chart is filled (hours) __________________________________((hours))

Number of times fluids recorded as checked during the 1period of monitoring (i.e. timeframe above) 2

345678910>10Empty

Evidence of monitoring baby's weight? Yes No




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Discharge Information

*Clinical review during discharge (this should be on a discharge summary sheet but look through the

entire file for this information)*

Date of discharge/death __________________________________((for empty date type 1915-01-01))

Outcome of discharge AliveDeadReferredAbscondedEmpty

Referred to where (name of facility)? Kenyatta national hospitalAga khan hospitalMbagathi District hospitalNairobi HospitalMama Lucy Kibaki hospitalNairobi west hospitalPumwani maternity HospitalThe Karen HospitalMater HospitalRadiant Pangani HospitalSt Francis Com HospitalMp Shah HospitalNairobi Women's Hospital (Hurlingham)Nairobi Women's Hospital (Adams)Alliance Medical CentreRuaraka Uhai Neema HospitalAvenue HospitalCoptic HospitalGertrudes children's HospitalGuru Nanak HospitalLangata HospitalMaria immaculate health centreMother and Child hospitalNairobi East HospitalNairobi South HospitalSkyhill Medical CentreAfwan Medical ClinicMeridian Equator HospitalMetropolitan HospitalSouth B Hospital LimitedFamily care medical centreKomarock Modern Medical CareMarura Nursing HomeSt Mary's Mission HospitalAl-Amin Nursing HomeLadnan HospitalEmpty

Facility referred to not on lookup list? Not on list

Specify facility/location not on lookup list __________________________________

Discharge weight (in kg) __________________________________(in kilograms. Only enter in kg or g, not both. Ifempty enter -1)



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Discharge weight (in g) __________________________________(in grams. Only enter in kg or g, not both. Ifempty enter -1)

Discharge diagnosis

Clear primary discharge diagnosis? Yes No Empty/No diagnosis(Select 'Empty' if no diagnosis is available)



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Primary discharge diagnosis Accompanying other twinAKIAdmitted due to mother's conditionAdmitted for observationAlbinismBABirth traumaBrachial plexus InjuryBurnsCaput SuccedaneumCephalohaematomaCerebral palsyChest malformationCBBAChorioamnitisCleft palateCHDCTEVCystsDehydrationPoor feedingDIBDistended abdomenEONsEpispadiaErb's palsyExtra digit on handFacial oedemaFebrile convulsionsFrothingGastrointestinal bleedingGrunting respirationHaematomaHepatitisHypersecretionHypoglycaemiaHypospadiaHypothermiaHIEImperforate anusInfection exposureIURGneonatal jaundice,NNJJointed penisLeft eye medial strabismusLeg hyperextension in deliveryLipomaLALarge for gestational age,LGAMAMBACesarean section,CSMother has no breast milkMothers drug abuseNasal blockage/Blocked nostrilsNEC, NECNeonatal AnaemiaNeonatal convulsionsNMNNS,EONS,NNTNRDS,RDS, Respiratory Distress SyndromeParaphimosisPhimosisPneumoniaPneumonitis/pulmonitisPolycythemia VeraPoor apgar scorePostdatismPremature labour



Primary discharge diagnosis not listed? Not on list

Specify primary discharge diagnosis not listed __________________________________(Specify diagnosis)


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Discharge diagnosis 1 Accompanying other twinAKIAdmitted due to mother's conditionAdmitted for observationAlbinismBABirth traumaBrachial plexus InjuryBurnsCaput SuccedaneumCephalohaematomaCerebral palsyChest malformationCBBAChorioamnitisCleft palateCHDCTEVCystsDehydrationPoor feedingDIBDistended abdomenEONsEpispadiaErb's palsyExtra digit on handFacial oedemaFebrile convulsionsFrothingGastrointestinal bleedingGrunting respirationHaematomaHepatitisHypersecretionHypoglycaemiaHypospadiaHypothermiaHIEImperforate anusInfection exposureIURGneonatal jaundice,NNJJointed penisLeft eye medial strabismusLeg hyperextension in deliveryLipomaLALarge for gestational age,LGAMAMBACesarean section,CSMother has no breast milkMothers drug abuseNasal blockage/Blocked nostrilsNEC, NECNeonatal AnaemiaNeonatal convulsionsNMNNS,EONS,NNTNRDS,RDS, Respiratory Distress SyndromeParaphimosisPhimosisPneumoniaPneumonitis/pulmonitisPolycythemia VeraPoor apgar scorePostdatismPremature labour



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Specify any other discharge diagnosis __________________________________(Specify diagnosis, separated by :)

Other discharge diagnosis Yes No


Confidential of 52

Other discharge diagnosis 1 Accompanying other twinAKIAdmitted due to mother's conditionAdmitted for observationAlbinismBABirth traumaBrachial plexus InjuryBurnsCaput SuccedaneumCephalohaematomaCerebral palsyChest malformationCBBAChorioamnitisCleft palateCHDCTEVCystsDehydrationPoor feedingDIBDistended abdomenEONsEpispadiaErb's palsyExtra digit on handFacial oedemaFebrile convulsionsFrothingGastrointestinal bleedingGrunting respirationHaematomaHepatitisHypersecretionHypoglycaemiaHypospadiaHypothermiaHIEImperforate anusInfection exposureIURGneonatal jaundice,NNJJointed penisLeft eye medial strabismusLeg hyperextension in deliveryLipomaLALarge for gestational age,LGAMAMBACesarean section,CSMother has no breast milkMothers drug abuseNasal blockage/Blocked nostrilsNEC, NECNeonatal AnaemiaNeonatal convulsionsNMNNS,EONS,NNTNRDS,RDS, Respiratory Distress SyndromeParaphimosisPhimosisPneumoniaPneumonitis/pulmonitisPolycythemia VeraPoor apgar scorePostdatismPremature labour



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Other discharge diagnosis 2 Accompanying other twinAKIAdmitted due to mother's conditionAdmitted for observationAlbinismBABirth traumaBrachial plexus InjuryBurnsCaput SuccedaneumCephalohaematomaCerebral palsyChest malformationCBBAChorioamnitisCleft palateCHDCTEVCystsDehydrationPoor feedingDIBDistended abdomenEONsEpispadiaErb's palsyExtra digit on handFacial oedemaFebrile convulsionsFrothingGastrointestinal bleedingGrunting respirationHaematomaHepatitisHypersecretionHypoglycaemiaHypospadiaHypothermiaHIEImperforate anusInfection exposureIURGneonatal jaundice,NNJJointed penisLeft eye medial strabismusLeg hyperextension in deliveryLipomaLALarge for gestational age,LGAMAMBACesarean section,CSMother has no breast milkMothers drug abuseNasal blockage/Blocked nostrilsNEC, NECNeonatal AnaemiaNeonatal convulsionsNMNNS,EONS,NNTNRDS,RDS, Respiratory Distress SyndromeParaphimosisPhimosisPneumoniaPneumonitis/pulmonitisPolycythemia VeraPoor apgar scorePostdatismPremature labour



Specify any other discharge diagnosis __________________________________(Specify diagnoses, separating each by :)

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