PHYSICAL EXAMINATION

GENERAL
SURVEY
Baby is awake, comfortable, no gross
malformations observed and not in
cardiorespiratory distress
 CARDIO-RESPIRATORY SYSTEM

(-) axillary lymph node enlargement

Symmetrical chest expansion, normal breath
sounds, no heaves, thrills, wheezes or
crackles
Adynamic precordium, heart rate of 176 bpm
with regular rhythm, no murmurs or rubs
Good and regular pulses*
 SKIN AND
Skin NAILS
• 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)
 ANTHROPOMETRIC MEASUREMENTS
AND VITAL SIGNS
Head Circumference: 33 cm
Chest Circumference: 29 cm
Abdominal Circumference: 30cm
Length: 47 cm
Weight: 1.90
kg
Temperature: 38.1 °C
HR: (ear)
RR: 176 bpm
Good Pulses* 64 bpm
 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*
 HEAD AND
Face NECKnormal facial features when crying (like
(-) gross deformities,
wrinkling of the forehead, wide opened mouth)
Eyes (+) aligned with respect to auricles, eyebrows symmetrical
anicteric sclera 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
 CARDIO-RESPIRATORY SYSTEM
RR 64 bpm and not in cardiorespiratory
distress*, high pitch cry (normal na cry ng babies)
(-) cyanosis, alar flaring, use of accessory
muscles forbreathing
(-) 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)
 EXTREMITIE
S
(-) rashes, abnormal skin color changes
(-) swelling and edema, muscle atrophy*,
deformities
(-) nodularities, masses
Full range of motion upon passive and active
manipulation
 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)