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NORMAL NEWBORN: HISTORY AND PHYSICAL EXAM OUTLINE

Infant:

Birth weight, gestational age, intrauterine growth (AGA, SGA, LGA), race, sex, date and time of birth.

Maternal:  

Age; Gravida     , Para                , SAB     , TAB     , SB       , LC       ; blood type, VDRL/RPR (date and results), race, EDC.  Previous complications of pregnancy, labor, delivery.  Type of contraception used, if any.  Was present pregnancy planned?

Pregnancy:

Location of prenatal care and number of visits.  Complications of pregnancy: Special test, ultrasound exams, stress tests. Medications - drug, dose, route, length of therapy, indication, when used during pregnancy.

Labor and Delivery:

  • Labor spontaneous or induced?
  • Complications of labor
  • Fetal monitoring?  Fetal distress?
  • Rupture of membranes: artificial or spontaneous, hours before delivery, character of fluid.
  • Medications - including analgesia and anesthesia: drug, dose, route, time prior to delivery
  • Duration - Stage I, Stage II, Stage III
  • Vaginal - or C-section delivery
  • Fetal presentation and position
  • Forceps used?  If so, state type and indication
  • Apgars 1 min/5 min (Specify points lost at each)
  • Resuscitation: none; bulb suction; free flowing oxygen; bag and mask; intubation, drugs used (dose and route)

 

Transitional Nursery:

  • VS on admission (including BP and temperature)
  • Hematocrit
  • Dextrostic
  • Problems: cyanosis, respiratory distress, etc.
  • Estimate of gestational age by Dubowitz - physical score, neuromuscular score
  • Family:

    Relationship of neonate's mother and father (married, divorced, cohabiting, live apart, no contact maintained, etc.)

    Mother: amount of education, and is she employed outside of the home?

    Father: age, amount of education, occupation

    Any illnesses or other problems in household members?

    Any significant illnesses (physical, mental, growth failure) in other members of father's or mother's family?  If so, what?

    Is there any disorder(s) in particular that mother worries her child might develop?

    Environment:

    • Type of housing (trailer, apartment, etc.)
    • Number of bedrooms; running water, bath; explain problems.
    • Is adequate heating or cooling a problem?  If yes, explain.
    • Is there a crib or adequate substitute for the baby?
    • Do any of the children sleep in the same bed or same room as their parents?
    • Are there adults other than the parents sleeping or living in the house?
    • Approximate level of income.  Are there a lot of debts?
    • Will the baby be an added financial stress?
    • Any previous contact with social agencies?  If so, which ones and opinions about the reasons for using the resources.
    • Any relatives or friends in town?  Type of support systems they provide?

    Mother-Child Relationship:

    Mother's affect; attitude toward the child; knowledge of child care.

     

    PHYSICAL EXAMINATION

    Vital Signs:  T ___    C     Weight ___     gm (% of Colorado Intrauterine Growth Curve)

    P ___  Length ___cm (% of Colorado Intrauterine Growth Curve)

    R ___  Head Circumference ___cm (%  "            "       "  )

    BP ___ Chest Circumference ___cm (% "            "       "  )

    General: Describe resting posture, activity, gross abnormality, color (pink, cyanotic/acrocyanotic, pale mottled)

    Skin: Texture, lanugo, vernix, meconium staining, icterus, hemangioma, nevi, rash, excoriation, petechiae, bruises.

    Head: General shape, molding, caput, cephalohematome, sutures (over-riding, separated), craniotabes.  Fontanel - anterior, posterior (presence, size, flat/full).  Texture of hair.

    Eyes: Edema, conjunctival or anterior chamber hemorrhage, discharge.  Size of eye; cornea, iris normal?  Lens clear?  Red reflex present?  Retina visualized?  PERL?

    Nose: Internal and external nares patent?  Septum midline?  Drainage present?

    Ears: Cartilaginous development of the ear lobe, position of ears, shape of auricle (normal/abnormal), preauricular sinus or skin tags.  External auditory canal patent.

    Mouth: Palate (intact, narrow or high arched), Epstein's pearls, mucosal cysts, teeth, tongue (size, position), frenulum, uvula.

    Chin: Micrognathia.

    Neck: Trachea position.  Masses (thyroid, sternocleidomastoid, etc.), cysts, sinus tracts, movement, nodes.

    Chest: Symmetry.  Breast buds (measure diameter in mm).  Clavicles intact?  Supernumerary nipples?  Axillary adenopathy.

    Lungs: Retractions, flaring, grunting, tachypnea, auscultation (rales, rhonchi, wheezes)

    CVS: PMI, rhythm, rate (tachycardia, bradycardia)

    S1, S2 (amplitude equal?  S2 split?)

    Murmur (quality, intensity, duration, relation to cardiac cycle, radiation, location of maximum intensity)

    Peripheral pulses - femoral, brachial, radial (amplitude, equality, simultaneous)

    Peripheral perfusion (capillary filling time)

    Abdomen: Shape, muscle tone, number of umbilical vessels, hernia/diastasis.  If palpable, note size and consistency of liver, spleen, kidney, or other masses.  Inguinal adenopathy?

    Genitourinary:  

    Female- size of clitoris and labia, masses in labia, hymenal tags, discharges, abnormalities in voiding.

    Male - urethral meatus patency and position, chordee, testicular descent and scrotal development (i.e., rugae only on inferior aspect, or surface completely covered with rugae and pendulous in appearance).  Hernia or hydrocele, abnormalities in voiding.

    Anus: Patency, anal wink, abnormal stooling.

    Extremities: Symmetry, ROM, abduction of hips, position of hands and feet.

    Number, shape, length of digits, length of nails, Palmar creases normal?  Subcutaneous tissue normal?

    Spine: Sinus tracts, sacral dimple, scolioses

    Neurologic:

    Tone:  active

    Dubowitz (Ballard form); also ventral supervision

    Head lag; leg and trunk straightening passive

    Cry: character, intensity, frequency

    Behavior: alertness, wakefulness, irritability, consoleability, cuddliness

    Reflexes:

           Suck         Grasp (palmer/plantar)           Pacing           Cross extension

           Root          Tonic neck           Stepping          Glabellar tap

           Moro           Galant            Rotation              Palmar-mentum

    DTRs (knee, angle, plantar, triceps, biceps) draw figure

    Tremor, clonus present?

    Paralysis: facial brachial

    Estimated Gestational Age:                                 

    ___ EDC           ___ Dubowitz    __   _ Obstetrical Prenatal Assessment                           

    PROBLEM LIST

    1.  Health Care Maintenance (HCM)

    2.  Per history and physical (list plan with each problem)

     

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Tucson, Arizona 85724
Phone: (520) 626-6053

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