Sample Type / Medical Specialty: General Medicine
Sample Name: Normal Newborn H&P Template
Template for History and Physical for a newborn.
(Medical Transcription Sample Report)
HISTORY OF PRESENT ILLNESS:
This is a ** week gestational age ** delivered by ** at ** on **. Gestational age was determined by last menstrual period and consistent with ** trimester ultrasound. ** rupture of membranes occurred ** prior to delivery and amniotic fluid was clear. The baby was vertex presentation. The baby was dried, stimulated, and bulb suctioned. Apgar scores of ** at one minute and ** at five minutes.PAST MEDICAL HISTORYMATERNAL HISTORY:
The mother is a **-year-old, G**, P** female with blood type **. She is rubella immune, hepatitis surface antigen negative, RPR nonreactive, HIV negative. Mother was group B strep **. Mother's past medical history is **.PRENATAL CARE:
Mother began prenatal care in the ** trimester and had at least ** documented prenatal visits. She did not smoke, drink alcohol, or use illicit drugs during pregnancy.SURGICAL HISTORY:
Medications taken during this pregnancy were **.ALLERGIES:
VITAL SIGNS: Temperature **, heart rate **, respiratory rate **. Dextrose stick **. Ballard score by the RN is ** weeks. Birth weight is ** grams, which is the ** percentile for gestational age. Length is ** centimeters which is ** percentile for gestational age. Head circumference is ** centimeters which is ** percentile for gestational age.
GENERAL: **Alert, active, nondysmorphic-appearing infant in no acute distress.
HEENT: Anterior fontanelle open and flat. Positive bilateral red reflexes.
Ears have normal shape and position with no pits or tags. Nares patent. Palate intact. Mucous membranes moist.
NECK: Full range of motion.
CARDIOVASCULAR: Normal precordium, regular rate and rhythm. No murmurs. Normal femoral pulses.
RESPIRATORY; Clear to auscultation bilaterally. No retractions.
ABDOMEN: Soft, nondistended. Normal bowel sounds. No hepatosplenomegaly. Umbilical stump is clean, dry, and intact.
GENITOURINARY: Normal tanner I **. Anus patent.
MUSCULOSKELETAL: Negative Barlow and Ortolani. Clavicles intact. Spine straight. No sacral dimple or hair tuft. Leg lengths grossly symmetric. Five fingers on each hand and five toes on each foot.
SKIN: Warm and pink with brisk capillary refill. No jaundice.
NEUROLOGICAL: Normal tone. Normal root, suck, grasp, and Moro reflexes. Moves all extremities equally.DIAGNOSTIC STUDIESLABORATORY DATA:
Full term, appropriate for gestational age **.PLAN:
1. Routine newborn care.
2. Anticipatory guidance.
3. Hepatitis B immunization prior to discharge.
general medicine, history and physical, gestational age, newborn, prenatal,
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