Newborn Physical Exam Medical Transcription Sample Report / Words

PHYSICAL EXAMINATION:  VITAL SIGNS:  Weight 6 pounds 7 ounces, length 19 inches, head circumference 13-3/4 inches, and temperature 98.6.  GENERAL APPEARANCE:  This newborn appears to be a well-nourished, well-developed female.
HEENT:  Positive red reflex.  TMs clear bilaterally.  Nose is clear.  Throat is clear.  Mouth is intact and clear.  NECK:  Supple, no thyromegaly.  CHEST:  Clear to auscultation.  HEART:  Regular rhythm, no murmurs.  ABDOMEN:  Soft, no masses, bowel sounds present.  EXTREMITIES:  Hips:  No clicks, no clunks, and no subluxation.  Full range of motion.  Good femoral pulses, +2 bilaterally.  BACK:  Normal.  SKIN:  Normal.  NEUROLOGIC:  No focal deficits.

VITAL SIGNS:  Weight 7 pounds 15 ounces.  Height 20-1/2 inches.  Head circumference 14 inches.  GENERAL APPEARANCE:  An alert male in no acute distress.  SKIN:  Pink, no jaundice.  HEENT:  Red reflexes bilaterally.  TMs are normal bilaterally.  Throat is negative.  NECK:  Negative.  HEART:  Regular rate and rhythm with equal femoral pulses.  LUNGS:  Clear to auscultation.  ABDOMEN:   Soft, positive bowel sounds.  No distention.  The umbilicus is well attached.  EXTERNAL GENITALIA:  Genitalia show a healing circumcision with descended testes bilaterally and some slight fluid in the scrotum.  EXTREMITIES:  Hips are negative.  NEUROLOGIC:  He is alert, vigorous cry, good tone, nonfocal.

PHYSICAL EXAMINATION:  VITAL SIGNS:  Height 20-1/2 inches, weight 7 pounds 6 ounces, head circumference 14 inches.  HEENT:  Head is normocephalic.  Anterior fontanelle is open and flat.  Red-orange reflexes are positive in both eyes.  Nose is clear.  Mouth is clear.  NECK:  There is no neck mass.  CHEST AND LUNGS:  Symmetric.  Good air entry and clear breath sounds.  HEART:  Quiet precordium.  Regular rhythm.  No murmurs heard.  Normal first and second heart sounds.  ABDOMEN:  Flat, not distended, soft, no mass, no tenderness.  The umbilical cord is dry, but still attached.  
EXTERNAL GENITALIA:  Normal male.  Both testes are descended.  His circumcised penis has already healed nicely.  He has perianal rash and a small amount of stool in his perianal area.  SKIN:  Generally clear.  He has some salmon patches on his forehead, on his nape, and on his buttocks.  NEUROLOGIC:  Examination is grossly intact and normal. 

VITAL SIGNS:  Height 29 inches, weight 19 pounds.  Head circumference 18-3/4 inches.
GENERAL APPEARANCE:  He is normocephalic, atraumatic.  The anterior fontanelle is open and flat.
SKIN:  Fair.
HEENT:  TMs normal bilaterally.  Pupils are equal and reactive to light.  Extraocular muscles intact.  Negative cover test.  Positive red reflex.  Throat is negative.
NECK:  Negative.
LUNGS:  Clear to auscultation.
HEART:  Regular rate and rhythm with equal femoral pulses.
CHEST:  A noticeable irregularity on his lower ribs.
ABDOMEN:  Soft, positive bowel sounds.  No hepatosplenomegaly with a very small umbilical hernia.
EXTERNAL GENITALIA:  Genitalia show descended testes.
EXTREMITIES:  Hips are negative.
NEUROLOGICAL:  He is very alert.  Good tone.  Smiling and social.  DTRs are equal. Cranial nerves intact, nonfocal.

VITAL SIGNS:  Weight 1945 g, head circumference 30.6 cm, length 44.8 cm. Temperature 36.6 degrees Celsius, heart rate 148, respiratory rate 80 to 108, blood pressure 48/20.
GENERAL:  This infant is active, quiet, calm under the radiant warmer.
HEENT:  Normocephalic.  Anterior fontanelle soft and flat.  Trisomy 21 face.
CHEST:  Symmetric movement.
LUNGS:  Clear to auscultation bilaterally.
HEART:  A 2/6 murmur.
ABDOMEN:  Soft with bowel sounds auscultated in all 4 quadrants.  No hepatosplenomegaly.
GENITOURINARY:  Normal male genitalia.  Testes palpable bilaterally in the scrotum.  Anus appears patent.
SPINE:  Straight. No tufts, no clefts.
SKIN:  Intact and warm.
NEUROLOGIC:  Moro, suck, and grasp reflexes are elicited.

VITAL SIGNS:  The baby's birth weight was 3590, current weight is 3640, FOC is 35.6 cm, length is 49.7 cm.  Temperature is 36.6, heart rate 170, respiratory rate 60, blood pressure 64/32.
GENERAL:  Active and alert, in no acute distress.
HEENT:  Anterior fontanelle is soft and flat.  Sutures normally approximated.  Ears are normally set.  Palate is intact without defects.  Red reflexes are present bilaterally.
NECK:  Soft and supple without adenopathy.  Clavicles are intact.
HEART:  Regular rate and rhythm without S3, S4, no murmurs.
LUNGS:  Clear to auscultation.  No rales, rhonchi or wheezing.
ABDOMEN:  Soft, nontender, without hepatosplenomegaly.
SKIN:  Pink and well perfused.  No rashes or lesions noted..

VITAL SIGNS:  Height 27 inches, weight 17-1/4 pounds.  Head circumference 17-1/2.
GENERAL APPEARANCE:  He is a well-nourished, happy, alert, very social male in no acute distress.
SKIN:  Fair.
HEENT:  Anterior fontanelle is open and flat.  TMs normal bilaterally.  Pupils are equal and reactive to light.  Red reflex bilaterally.  Negative cover test.  Extraocular muscles intact.  Throat is negative.
NECK:  Negative.
LUNGS:  Clear to auscultation.
HEART:  Regular rate and rhythm with equal femoral pulses.
ABDOMEN:  Soft, positive bowel sounds.  No hepatosplenomegaly.
EXTERNAL GENITALIA:  Descended testes bilaterally with circumcised penis.
EXTREMITIES:  Hips are negative.
NEUROLOGIC:  DTRs are equal.  Puts weight on his legs.  Very happy, very interactive, very vocal.  Cranial nerves intact.  Normal musculature.  Normal tone.  Nonfocal. 

PHYSICAL EXAMINATION:  GENERAL APPEARANCE:  She is a healthy-looking, 1-month-old infant.  VITAL SIGNS:  Length is 22-1/4 inches, weight is 9 pounds.  Head circumference 14-1/2 inches.  HEENT:  Head is normocephalic.  Anterior fontanelle is open and flat.  Red-orange reflexes are positive in both eyes.  Extraocular muscles are intact.  Nose is clear.  Mouth is clear.  NECK:  There is no neck mass.  CHEST AND LUNGS:  Symmetric.  Good air entry.  Clear breath sounds.  HEART:  Nonactive precordium.  Normal first and second heart sounds, regular rhythm.  No murmurs.  
ABDOMEN:  Soft.  No hepatosplenomegaly.  No mass.  Umbilicus is dry.  EXTERNAL GENITALIA:  Normal female.  EXTREMITIES:  Femoral pulses are easily palpable.  Hips are stable.  Negative Ortolani and negative Barlow sign, and negative Galeazzi.  SKIN:  Clear.  SPINE:  Straight.  No sacral dimple.  NEUROLOGIC:  Grossly intact. 

GENERAL APPEARANCE:  He is a healthy-looking toddler.
VITAL SIGNS:  Height 34 inches, weight 29 pounds.  Head circumference 28-1/2 inches.
HEENT:  Head is normocephalic.  Anterior fontanelle is now small, but still open.  Red-orange reflexes are positive in both eyes.  Both conjunctivae are clear.  Pupils are equal and reactive to light.  Nose is clear.  Mouth is clear.
NECK:  No neck mass. 
CHEST AND LUNGS:  Symmetric.  Good air entry and clear breath sounds. 
HEART:  Normal.  No murmurs, regular rhythm. 
ABDOMEN:  Flat, soft, no mass, no tenderness. 
EXTERNAL GENITALIA:  Normal male. Both testes are down. 
EXTREMITIES:  Full range of motion.  No deformity.  Negative Galeazzi sign. 
BACK:  Straight. 
SKIN:  Clear. 
NEUROLOGIC:  Examination is grossly normal.

GENERAL:  He is awake, alert and in no acute distress.
VITAL SIGNS: Weight is 11 pounds 11 ounces. Temperature is 98.6, pulse 122 per minute, and respiratory rate 24 per minute. 
HEENT:  Head is atraumatic with a flat right occiput on the right temporal area.  Red macular rash on his anterior neck area with some slight pressuring on either side with red macular rash under his right axilla.  Eyes:  PERRLA.  Clear conjunctivae bilaterally.  Ears:  Normal TMs and canals bilaterally.  Throat has no erythema. 
CHEST:  Lungs are clear bilaterally.
HEART:  Normal S1 and S2.  No murmurs.
ABDOMEN:  Soft, nontender and no organomegaly.
LYMPHATICS:  No enlargement.
NEUROLOGIC:  Normal DTRs.  Negative Babinski.

VITAL SIGNS:  Today, vital signs are stable.  She is afebrile.
SKIN:  She has one deep pigmented spot and one cafe au lait spot, but no other significant dysmorphic features or skin stigmata.
HEENT:  Anterior fontanelle is flat and soft.
CARDIAC:  S1 and S2 are audible.  No significant murmur.
ABDOMEN:  Benign.
NEUROLOGIC:  She is alert, active, not in acute distress.  She is normocephalic.  Extraocular movements are full.  There is no facial asymmetry.  Tongue is midline.
MOTOR EXAMINATION:  Revealed normal tone and bulk.  Deep tendon reflexes are 2+/4 bilateral, symmetrical, with flexor plantar responses.
SENSORY EXAMINATION:  Revealed normal withdrawal.  No dysmetria or tremors.

VITAL SIGNS:  Weight 22 pounds, temperature 98.2, pulse 104 per minute, and respiratory rate 24 per minute.
GENERAL:  She is awake, alert, in no acute distress.
HEENT:  Head atraumatic and normocephalic.  AF open, flat.  Eyes:  PERRLA.  Clear conjunctivae bilaterally.  Ears:  Normal TMs and canals bilaterally.  Throat:  No erythema.
LUNGS:  Clear bilaterally.
HEART:  Normal S1 and S2.  No murmur.
ABDOMEN:  Soft and nontender.  No organomegaly.
LYMPHATICS:  No enlargement.
SKIN:  Hyperpigmented macules, diffuse on trunk, abdomen, legs and extremities.  No petechiae.
NEUROLOGIC:  Normal DTRs.  Negative Babinski.  Normal tone. 

GENERAL:  She is awake, playful, in no acute distress.
VITAL SIGNS:  The patient has a weight of 21 pounds, temperature 98.4, pulse 120 per minute, respiratory rate 22 per minute, blood pressure 94/56.
SKIN:  No rashes or petechiae.
HEENT:  Eyes:  PERL.  Clear conjunctivae bilaterally.  Ears:  Normal TMs and canals bilaterally.  Throat:  No erythema.
HEART:  Normal S1 and S2, within normal limits.  Pulse is adequate.
LUNGS:  Clear bilaterally. 
ABDOMEN:  Soft, nontender.  No organomegaly.
GENITALIA:  No rashes.  Tanner I female.
LYMPHATICS:  No enlargement.
EXTREMITIES:  No deformity.
NEUROLOGIC:  Normal tone.

VITAL SIGNS:  Temperature 98.6, pulse 114, respiratory rate 30, blood pressure 112/52, weight 6.3 kilograms, height 64 cm, head circumference 41.8 cm, measurements are within normal limits.
GENERAL:  The patient is alert, active, in no distress, well hydrated and well nourished.  Capillary refill 2 seconds.
HEENT:  Head:  Normocephalic and atraumatic.  Fontanelle flat.  Eyes:  Pupils equal and reactive to light and accommodation.  Extraocular movements intact.  No erythema or discharge.  Fundi are normal.  Vision is normal.  Ears:  Auricles normal.  Canals are clear.  Tympanic membranes are intact.  Hearing is okay.  Noted cerumen impaction bilaterally.  Nose: Clear without discharge, symmetrical, no deformity.  Throat:  Clear without erythema or exudate.  Tonsils are not enlarged.  Normal oral mucosa and teeth.
NECK:  Full range of motion of neck.  No meningismus.  No masses.  Thyroid is normal.  No lymph nodes enlarged anywhere.
CHEST AND LUNGS:  Clear to auscultation bilaterally.  No retractions, equal breath sounds.
HEART:   Regular rate and rhythm.  S1 and S2 normal.  No clicks, murmurs or gallops.
BREASTS:  Not applicable.
ABDOMEN:   Nontender, nondistended, and soft.  No organs enlarged.  No masses.
RECTAL:  Normal.  Stool:  Normal.
BACK:  Straight spine.  No deformity.  Spine nontender. CVA nontender.
GENITOURINARY:  Normal vulva.  No discharge.  Hymen intact.
EXTREMITIES:  Gait not applicable.  No joint swelling or tenderness.  Full range of motion.
SKIN:  Warm, dry, and pink.  Turgor is normal; however, noted diaper rash is visible, satellite lesions, and erythema of bilateral buttocks.  However, no lesions of groin, skin folds.
NEUROLOGIC:  Sensorium is intact.  Cranial nerves are intact.  Motor and sensory are intact.  Cerebellum intact.  Deep tendon reflexes 2+ in all extremities.  Development is normal.

GENERAL:  Well-developed, well-nourished male child, appears comfortable. 
VITAL SIGNS:  Stable, normal, afebrile, O2 saturation is normal at 98% on room air. 
ENT:  Moist mucous membranes. Airway patent. He does have a hyperemic posterior pharynx with some enlarged tonsils but no exudate, no airway obstruction. Some clear rhinorrhea and edematous nasal turbinates of the nose. Ears reveal hyperemic TMs bilaterally with no bulging. No loss of landmarks. 
NECK:  Supple, no nuchal rigidity. No significant lymphadenopathy. 
HEART:  Regular rate and rhythm, S1, S2. 
LUNGS:  Mostly clear to auscultation bilaterally. No retractions or accessory muscle use. 
ABDOMEN:  Soft, nontender. Bowel sounds are present. 
SKIN:  Warm and dry. 
EXTREMITIES:  Without cyanosis. 
NEUROLOGIC:  He was sleeping initially but he woke up, responds normal to any tactile stimulation. Makes good eye contact. Fontanelle is fused. 

GENERAL: Well-developed, resting in mother's arms, nontoxic. 
VITAL SIGNS: Temperature is 99.2, pulse 120, respirations 46, room air pulse ox 98%, within normal limits. 
HEENT: Anicteric sclerae. Good red reflex. Pupils are equal, round, and reactive to light. Bilateral TMs clear. Normal anterior fontanelle. Oropharynx is clear. Moist mucous membranes. Chest wall is without crepitation. 
HEART: Regular rate and rhythm without murmurs. 
LUNGS: Clear to auscultation bilaterally, no signs of intercostal retractions or respiratory extremis, very tight. 
ABDOMEN: Soft, positive bowel sounds, nontender. 
EXTREMITIES: No clubbing, cyanosis or edema. 
NEUROLOGIC: Good Moro reflex. Reflexes are 1+. Moves all four extremities. Good suck reflex.

VITAL SIGNS:  Weight 2760 g, length 48.4 cm, head circumference 33.2 cm, temperature 37.2 axillary, heart rate 122, respiratory rate 62, blood pressure 68/46.
GENERAL:  Term male, in no distress.
HEENT:  Normocephalic.  Anterior fontanelle is open and flat.  Eyes and ears are grossly normal.  Nares patent.  Palate intact.  Clavicles supple.  Red reflex present on admission.
THORAX:  Symmetric.
LUNGS:  Bilateral breath sounds are clear and equal.
CARDIOVASCULAR:  Heart rate and rhythm regular without a murmur.  Precordium is silent.  Pulses are 2+ and equal.  Capillary refill is brisk.
ABDOMEN:  Soft, round with active bowel sounds.  No hepatosplenomegaly or masses noted.  Cord intact and dried.
GENITOURINARY:  Male genitalia with testes descended bilaterally.  Anus patent.
MUSCULOSKELETAL:  Spine alignment is within normal limits.  Appropriate number and spacing of digits.  Hip exam is within normal limits.
NEUROLOGIC:  Infant is active, alert, moves all extremities well.  Tone is appropriate for age.
SKIN:  Intact and pink. 

PHYSICAL EXAMINATION:  The baby is alert, awake, active, and in no distress.  Head is clear.  Ears, nose, and throat are clear.  Neck is supple.  No masses.  Respiratory system is clear bilaterally.  No wheezing.  No rales.  Cardiovascular system:  S1, S2, rhythmic, no murmurs.  Abdomen is soft and nontender.  No hepatosplenomegaly.  No masses.  Skin:  There is a faint, thin erythematous rash over the arm and trunk.  No purpuric blanching.  Extremities are normal.  CNS:  Nonfocal.  Anterior fontanelle is open and flat.

VITAL SIGNS: Temperature 96.4, rectal; pulse 146; respirations 34; pulse oximetry 92-93% on room air. This was repeated and found to be at 99%. 
GENERAL: This is a 4-day-old male child. He has his eyes closed. He is uncovered. He is moving his arms and legs vigorously. He is not crying. He does not appear jaundiced. His skin does appear very dry and some areas are peeling. 
HEENT: The head is normocephalic and atraumatic. The anterior fontanelle is without depression or bulge. The pupils are equal, round, and reactive to light. He also has a good red light reflex. Oropharynx is normal without erythema, edema or exudate. No signs of thrush. He is age appropriate. The mucous membranes are moist. He does have a greenish discharge in the left naris. There is no edema noted in the turbinates or erythema. 
NECK: Supple without meningismus. There is no lymphadenopathy. 
LUNGS: Clear to auscultation. Equal breath sounds bilaterally. No wheezes, rales, rhonchi, crackles or stridor noted. Respiratory excursion is symmetrical. No sternal retractions. 
HEART: Regular rate and rhythm. No murmurs, gallops, rubs or clicks. 
ABDOMEN: Soft, nontender, nondistended. There are no masses or organomegaly. Positive bowel sounds, all four quadrants. No guarding or rebound. 
SKIN: Warm and dry. Again, it does appear very dry, and in places, it is peeling. His hips have no clicks. He was just circumcised yesterday. The glans penis is slightly erythematous and does not appear to be infected. The right testicle is down; left testicle is not. There is no diaper rash. The rectum appears normal.

PHYSICAL EXAMINATION:  His weight is 4.9 kg, blood pressure is 89/54. HEENT:  Flat fontanelle. Lungs:  Clear breath sounds. Heart:  S1 and S2, normal. No murmur. Abdomen:  Soft and full abdomen. Spleen is 2 cm. Liver is up to umbilicus. Genitalia:  Normal male features with micropenis. Testes descended bilaterally. Neurological:  Responsive, active, intact. Spine: Straight, without masses. Moving all extremities. Skin: Pink and warm.

PHYSICAL EXAMINATION:  On general examination, the child is healthy in appearance. He is in no apparent distress when held in his mother's lap. Examination of head and neck does not demonstrate any significant abnormality. His sclerae are normal in color. Examination of the upper extremities and trunk is normal. On examination of lower extremities, he has some slight swelling of the right thigh. He is clearly tender to palpation of the right thigh. He does not seem to be tender to palpation over the lower leg, ankle or foot. He does have some apparent pain with movement of the right lower extremity. He does not tend to move the right hip and knee as much as the left. The left lower extremity does not seem to be tender over the thigh, knee or lower leg.