Sample Name: Normal Newborn Infant Physical Exam
Description: Normal newborn infant physical exam. A well-developed infant in no acute respiratory distress.
(Medical Transcription Sample Report)
GENERAL: A well-developed infant in no acute respiratory distress.
VITAL SIGNS: Initial temperature was XX, pulse XX, respirations XX. Weight XX grams, length XX cm, head circumference XX cm.
HEENT: Head is normocephalic with anterior fontanelle open, soft, and non-bulging. Eyes: Red reflex elicited bilaterally. TMs occluded with vernix and not well visualized. Nose and throat are patent without palatal defect.
NECK: Supple without clavicular fracture.
LUNGS: Clear to auscultation.
HEART: Regular rate without murmur, click, or gallop present. Pulses are 2/4 for brachial and femoral.
ABDOMEN: Soft with bowel sounds present. No masses or organomegaly.
EXTREMITIES: Without evidence of hip defects.
NEUROLOGIC: The infant has good Moro, grasp, and suck reflexes.
Keywords: general medicine, fontanelle, normocephalic, newborn infant, physical exam, acute respiratory, newborn, respiratory, distress, head, infant,