Sample Name: Normal Newborn H&P Template
Description: 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 HISTORY
MATERNAL 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: Medications taken during this pregnancy were **.
FAMILY HISTORY: **
SOCIAL HISTORY: **
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.
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.
LABORATORY DATA: **
ASSESSMENT: Full term, appropriate for gestational age **.
1. Routine newborn care.
2. Anticipatory guidance.
3. Hepatitis B immunization prior to discharge.
Keywords: general medicine, history and physical, gestational age, newborn, prenatal,