NORMAL NEWBORN: HISTORY AND PHYSICAL EXAM OUTLINE
Birth weight, gestational age, intrauterine growth (AGA, SGA, LGA), race, sex, date and time of birth.
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?
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:
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?
Mother's affect; attitude toward the child; knowledge of child care.
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.
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?
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
Dubowitz (Ballard form); also ventral supervision
Head lag; leg and trunk straightening passive
Cry: character, intensity, frequency
Behavior: alertness, wakefulness, irritability, consoleability, cuddliness
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
1. Health Care Maintenance (HCM)
2. Per history and physical (list plan with each problem)