Newborn Exam:

Example of a newborn write-up for a normal exam.

S: Female infant delivered vaginally at 0200 on 02-20-02 to a 23 year old

Hispanic G-2, P-1, who had spontaneous rupture of membranes 3 hours prior to delivery. Presentation was cephalic and labor was uneventful. Spontaneous cry with AGARS of 9 and 10. Mother is O+, known father is B+. RPR is negative, as is vaginal GBS. Mother denies difficulties with this or previous pregnancy. Reports only having an occasional glass of wine in the first month of pregnancy but stopped all ETOH as soon as pregnancy was known. Denies drug or tobacco use. Pregnancy was unplanned but wanted. Older sibling, male is at home and is a healthy 2 y.o. Father and maternal grandmother also live in the home. Mother will nurse the infant at least until she returns to work in 2 months, at that time she may continue to nurse if arrangements can be made for a breast pump. FH is positive for diabetes in maternal grandmother who is on insulin, HTN in paternal grandfather, no other congenital anomalies or inherited diseases.

O: Well developed, 7 hour old, WN infant female in NAD lying in warmer with all extremities flexed and rooting toward left fist. VS: T-37-C, (rectal); HR-140; RR-36; WT-3240 GM; HT-49.5 CM; OFC-34 CM.

SKIN: Warm dry and pink. No skin lesions/markings/nevi noted other than a blue-hyperpigmented marking at the base of the spine and medial, superior, left buttock.

HEENT: Head-normocephalic, fontanelles: anterior-4cm, flat; posterior-finter tip.

Slightly overriding suture lines. Hair-full, thick, dark brown.

Eyes- Sclera white, conjunctiva pink, PERRL, cornea and lens clear, red

reflex present bilat. Unable to visualize optic disc.

Ears- Normal position; Auricles symmetrical without lesions, no obvious

sinus tracts, canals filled with vernix.

Nose- Mucosa pink without lesions or discharge, septum midline, airway

patent.

Mouth/Throat- Mucosa moist, pink; lips, gums, tongue pink, moist,

without lesion; pharynx normal without erythema; uvula midline; hard and

soft palate intact to palpation. Good cry without hoarseness.

NECK: Full ROM, no lymphadenopathy, no obvious sinus tracts or webbing.

CHEST: Normal conformation. Clear to auscultation in all fields.

CV: HRRR without murmurs, heaves or thrills. Radial and femoral pulses

equal bilaterally.

ABDOMEN: Soft, without masses. Umbilical cord has 3 vessels and clamp in place.

No hepatosplenomegaly. Kidneys unpalpable. No inguinal nodes or hernias palpated.

EXTR: Symmetrical without deformities or length discrepancy, Symmetrical

muscle tone/strength/FROM throughout. No cyanosis or clubbing noted on nails. Ortalani and Barlow maneuvers negative.

NEURO: Moro, root, suck, step and place reflexes intact. Facial movements symmetrical.

GENITALIA: Normal appearing female with prominent hymen. Anus patent, stool present in diaper prior to exam.

(if male examine foreskin, look for unusual placement of urethral orifice,

testes present/not in scrotal sac)

A: Healthy appearing infant female at 6 hours of age.

P: Discussed newborn screening tests with parents. Will proceed with Hep B vaccine.

Parent education done regarding breast-feeding, sleeping positions, signes and

symptoms of illness, and other anticipatory guidance issues. An appointment for 2

week follow-up in the office will be provided by the ward clerk at discharge.

Discharge is planned for (date) at (time) pending no change in infant status.