PHYSICAL EXAMINATION AND REVIEW OF SYSTEMS

Date: November 1, 2020

Vital Signs:
Temp: 36.3C RR: 60 cpm Weight: 3.5 kg .
PR: 153 bpm BP: __________ Height: 54 cm .

Observation: _______________________________________________________________________________________

1. General (weight loss or

gain; fever, chills, night Pt. is asleep, (+) response when stimulated, without IVF/heplock, is under phototherapy, eyes covered with cloth with latest v/s: T:36.3C, PR: 153 bpm, SPO2
sweats; mood; stage of 95% with 02, RR: 60 cpm
development, race, sex;
signs of distress; position;
cooperative or not; state if
irritable, agitated or
pleasant; etc.)
2. Head (headache, injury,
tenderness, etc.); Eyes Head: anterior fontanelle felt like a soft spot, caput succedaneum is noted, The neck of a newborn is short and often chubby, with creased skin folds
(change in visual fields,
glasses, blurring, diplopia, Eyes: newborn’s eyes appeared clear, without redness
pain, loss of vision, tearing,
dry eyes, etc.); Ears Ears: ears have symmetrically aligned the eye, the level of the top part of the external ear should be on a line drawn from the inner canthus to the outer
(change in hearing, tinnitus, canthus of the eye and back across the side of the head newborn’s eyes should appear clear, without redness or purulent discharge,
discharge, dizziness, etc.);
Nose (allergies, sinus Nose: patient's nose is patent, no obstructions noted.
problem, obstruction,
polyps, sneezing, epistaxis, Mouth: Mucus (small) is found in mouth while sleeping, (-) cleft palate
etc.);Throat (toothaches,
loose teeth, bleeding gums,
mouth sores, hoarseness,
difficulty swallowing, etc.)
3. Integumentary System
acrocyanosis noted during the 1st minute of life, milia is evenly distributed, vernix caseosa evenly distributed throughout the body, yellowish skin and sclera
noted few hours after delivery

4. Respiratory System
(chest pain, dyspnea, usually cries and aerates the lungs spontaneously at about 30 seconds after birth, respirations are normally rapid (30 to 60 breaths per minute) but not
cough, amount and color of distressed. (-) crackles, (-) wheezing, (-) DOB/SOB
sputum, hemoptysis, etc.)

Patient’s Name / Room No. | 1

5.Cardiovascular System
(chest pain/ pressure/ PR: 153 bpm, CRT <3seconds, (-) murmurs, (-) DOB, (-) signs of distress, (-) clubbing, (-) edema
tightness, palpitations,
orthopnea, paroxysmal
nocturnal dyspnea,
shorntness of breath,
edema, claudication,
endurance, etc.)
6. Digestive System
(dysphagia, heartburn, The baby's umbilical cord is thick and shiny. After the first hour of life, the cord begins to dry and shrink. (-) presence of pus, (-) umbilical hernia, anus is patent,
ulcer, GERD, indigestion, free from lesions. Defecated twice with frequent and loose bowel movements with sometimes greenish in color stool
food intolerance, diarrhea,
constipation, abdominal
pain, blood in stool, black
tarry stools, changes in
bowel habits, reduced
caliber of stools,
hemorrhoids, etc.)
7. Excretory System
(urgency, frequency, pt. urinated when weighed, the urine appears clear, no presence of blood or pus
nocturia, dysuria,
hematuria, recurrent UTIs,
STD, incontinence, etc.)
8.Musculoskeletal System
(limitation in movement, The spine appears flat in the lumbar and sacral area, with no pinpoint/opening, (-)dimpling or sinus tract in the skin. The arms and legs appear short. The
stiffness, joint pain, swelling hands are plump and clenched into fists, fingernails are soft and smooth, and usually long enough to extend over the fingertips. Legs are bowed as well as
or redness, arthritis, muscle short. The sole of the foot appears flat because of an extra pad of fat in the longitudinal arch.
spasms, muscle weakness, Reflexes: (+) sucking reflex, (+) grasp reflex, (+) rooting reflex, (+) moro reflex, when you touched the patient's foot and moved your finger upward, the
etc.) newborn’s toes will fanned outward (+) babinski reflex.

9. Nervous System
The patient is asleep, reactive to stimulus. full flexion of arms and legs, 30 degree angle square window angle between hypothenar eminence and anterior
aspect of forearm, arm recoil less than 90 degree when forearm is flexed for 5 seconds then released, 90 degree popliteal angle, scarf sign:elbow does not
reach midline of thorax, heel to ear: 2

10. Endocrine System

(heat/cold intolerance, appears shivering when AC is on, (-) dysphagia, evenly distributed hair noted
weight change, fatigue,
polydepsia, polyuria,
polyphagia, changes in hair
distribution, etc.)
11. Reproductive System
Pt. is male, testes down with good rugae, scrotum is edematous and has rugae (folds in the skin), both testes present in the scrotum, the penis of newborns
appears small, approximately 2 cm long
Patient’s Name / Room No. | 2
Patient’s Name / Room No. | 3