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PHYSICAL EXAMINATION

PHYSICAL EXAMINATION. GENERAL SURVEY. Baby is awake, comfortable, no gross malformations observed and not in cardiorespiratory distress. ANTHROPOMETRIC MEASUREMENTS AND VITAL SIGNS. Head Circumference: 33 cm Chest Circumference: 29 cm Abdominal Circumference: 30 cm Length: 47 cm

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PHYSICAL EXAMINATION

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  1. PHYSICAL EXAMINATION

  2. GENERAL SURVEY Baby is awake, comfortable, no gross malformations observed and not in cardiorespiratory distress

  3. ANTHROPOMETRIC MEASUREMENTS AND VITAL SIGNS Head Circumference: 33 cm Chest Circumference: 29 cm Abdominal Circumference: 30 cm Length: 47 cm Weight: 1.90 kg Temperature: 38.1 oC (ear) HR: 176 bpm RR: 64 bpm Good Pulses*

  4. SKIN AND NAILS Skin • brown skin and pinkish palms and soles • Texture: smooth and supple to touch • Warm to touch • (-) jaundice, central and peripheral cyanosis Nails • (-) cyanosis, gross nail deformities, clubbing, inflammation Hair • black color, evenly distributed, smooth to touch, (-) alopecia, infestations, infection, masses (note: fontanels unassessed)

  5. HEAD AND NECK Face (-) gross deformities, normal facial features when crying (like wrinkling of the forehead, wide opened mouth) Eyes (+) aligned with respect to auricles, eyebrows symmetrical anictericsclera and pink conjunctiva (-) nodules, swellings, proptosis pupils round, regular in size, central and briskly reactive to light Ears (-) external deformities, inflammation, swelling, exudates, bleeding, discharges ears symmetrical in size (note: otoscopic evaluation unperformed) Nose (-) external deformities, inflammation Nasal Mucosa (-) erythema, inflammation, exudates Nasal Septum midline

  6. HEAD AND NECK Mouth Lips: (-) ulcers, cyanosis Buccal mucosa and gums: pink in color, (-) ulceration, pigmentation, nodularities, bleeding, no visible palate defects Teeth: Toothless Tongue: midline, normal in size and texture Neck (-) lymphadenopathy*, tracheal deviation thyroid not palpated, no visible carotid pulsations, (-) NVE, sternocleidomastoid muscles used only when crying (not while sleeping)

  7. CARDIO-RESPIRATORY SYSTEM RR 64 bpm and not in cardiorespiratorydistress*, high pitch cry (normal na cry ng babies) (-) cyanosis, alar flaring, use of accessory muscles for breathing (-) subcostal and supraclavicular retraction (-) prominent rib cage and clavicles (-) gross deformities anterior and posterior, but with slight depression in midline, subxyphoid area (mother says it has always been there)

  8. CARDIO-RESPIRATORY SYSTEM (-) axillary lymph node enlargement Symmetrical chest expansion, normal breath sounds, no heaves, thrills, wheezes or crackles Adynamicprecordium, heart rate of 176 bpm with regular rhythm, no murmurs or rubs Good and regular pulses*

  9. GIT AND GUT Flabby abdomen, symmetric in size and shape, umbilicus midline (-) visible masses, herniation, abnormal pulsations Hypoactive bowel sounds (0/m), no borborygmi (-) inguinal lymphadenopathy, clitoromegaly, other genital anomalies*

  10. EXTREMITIES (-) rashes, abnormal skin color changes (-) swelling and edema, muscle atrophy*, deformities (-) nodularities, masses Full range of motion upon passive and active manipulation

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