Sample Type / Medical Specialty: Office Notes
Sample Name: Normal Newborn Infant Physical Exam
Normal newborn infant physical exam. A well-developed infant in no acute respiratory distress.
(Medical Transcription Sample Report)
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.GENITALIA:
Without evidence of hip defects.NEUROLOGIC:
The infant has good Moro, grasp, and suck reflexes.SKIN:
Warm and dry without evidence of rash.
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