PHYSICAL ASSESSMENT

General Status:

Patient is a neonate placed side lying on crib, alert and awake, with good sucking reflex, with noticeable
back protrusion, plump and rounded overall figure.

Height: 52cm Weight: 3.9 kg

Vital Signs:

Temperature: 36.5 C Heart Rate: 140 bpm Respiratory Rate: 50 cpm

Body Part / Organ Findings Review of System

Skin I: Evenly distributed light brown, with mild
neonatal acne on both cheeks
P: Warm to touch, with good skin turgor

Hair I: Thick, shiny and dark, evenly distributed

Head I: Head circumference of 38cm, anterior SO: “Ingon ang doctor naa daw
fontanel is soft and non-bulging measured problema iya ventricle sa ulo”
3x5 cm
P: Soft anterior fontanels

Face I: Symmetrical, pinkish to reddish cheeks, “ Mapuwa ni iyang panit tungod

with mild to moderate neonatal acne sa iyang allergy sa sabon”
P: Warm, soft, non-tender
Eyes/ Ears/ Nose/ Eyes I: Symmetrical, dark brown, mildly
Mouth/ Throat cross eyed, PERRLA, voluntary eye
movement
Ears I: Symmetrical, bilateral pinkish in
color,
Ears P: Soft and non-tender
Nose I: Symmetrical, non-flaring, pinkish
with mild acne
Nose P: Soft and non-tender
Mouth I: Moist and pink gums with
absence of teeth, able to yawn and
voluntarily open (when crying)
Throat I: Midline, localized evenly
distributed fats at neck

Thorax / Chest/ Back I: Symmetrical chest, nipples, sternum at SO: “ Kadto pag panganak nako
midline, evenly distributed fine hair, chest kay breech man siya (patient)
circumference of 48cm with mass mura ug na igo iya likod pag
included, with lumbar meningocele, gawas mao siguro na puwa iya
erythematous, open with circumference likod”
9x9cm
P: Soft, palpable ribs
A: Clear breath sounds on both lungs
Heart and Blood Vessels I: Mild-moderate visible blood vessel, with
CRT of <1 second
P: Pounding heart beat
A: (+) Heart murmur, heart rate of 150
bpm
Upper Extremities I: Symmetrical, bilateral
voluntary movement, able to
resist, hands are closed, with
long fingernails
P: Soft, non-tender, warm

Abdomen I: Full, rounded, withered

umbilical cord stump, absence
of redness or swelling,
P: Soft
A: 13 clicks and gurgles per
minute
Genitals I: Male genitalia, mild swelling
of the scrotum

Lower Extremities I: Symmetrical, bilateral SO: “Dili man niya ma lihok iya
hypotonia with mild digital duh aka tiil, pero malihok2 niya ang
control, long fingernails iya tudlo”

GCS Spontaneous eye opening (4);

Follows to verbal response,
coos, fixes and follows (5);
Spontaneous motor response
(6).