Pe Kawas.docx

VIII. Physical Examination  General appearance: Patient is awake, active, afebrile and lying cuddled by grandmother. No cardiopulmonary distress noted. With ongoing IVF of  Vital Signs: o Heart rate: 36.2 bpm (Normal: 90-120bpm) o Respiratory rate (awake crying): 58 cpm (Normal: 30-45cpm) o Temperature (axilla): 36.5⁰C (Normal: 36.5⁰C -37.5⁰C)  Anthropometrics: o Weight: 7.5kg o Length: 74 cm o Head circumference: 44 cm o Chest circumference: 43 cm o Abdominal circumference: 50 cm  Skin: Skin is well hydrated. No jaundice nor pallor. Light brown in color. No rashes, + crusting on previous BCG injection, Warm to touch. Normal capillary refill <2secs. With minimal diaper rash in the inguinal area  Head: Head is normocephalic. Hair is black, average texture, and evenly distributed. Scalp has no lumps or lesions. Anterior and posterior fontanels is palpable. Face is round with symmetrical features and expressions.  Eyes: Eyes are symmetrical with equally distributed eyelashes and eyebrows. Outer canthus aligns with tips of the pinnas. Pink conjunctiva. White sclera. No discharge, lesions or redness, Pupils are equal in size, round and reactive to light and accommodation.  Ears: Normally set ears, symmetrical. in line with the inner and outer canthi of the eye. No discharge, excoriations, or foreign body in both external ears. Non- tender. Turn head in response to noise.  Nose: Nose at midline, nasal septum intact, no nasal flaring or discharges noted.  Mouth: + crusting of upper lips, Pinkish and moist oral mucosae. Tongue midline. No visible teeth.  Neck. Symmetric and no signs of deformity or swelling. No neck vein engorgement noted nor cyanosis and pallor. No palpable masses, lymph nodes and nodules.  Lymph Nodes: No axillary or epitrochlear nodes. No cervical, axillary, epitrochlear, inguinal adenopathy  Thorax and Lungs: Upon inspection, there is symmetric chest expansion and no chest wall deformities. No retractions and nasal flaring. Upon palpation, there is symmetric vibrations/fremitus on both side of the chest when the infant cries. Upon auscultation, there was no crackles and wheezes noted on both sides of the lung.  Cardiovascular: Adynamic precordium, regular rate and rhythm, no murmurs, full and equal pulses. There is no cyanosis noted,  Abdomen. Slightly protuberant. Umbilicus slightly inverted with no discharge, odor or redness noted. Normoactive bowel sounds. Soft and not irritable upon palpation.  Genitalia. Normal appearance. Grossly female. Labia majora and minora are pink and moist.  Rectal. Anal opening is patent and moist. + yellow soft stool upon inspection.  Musculoskeletal: No gross deformities, no edema and equal in length. Normal range of motion of upper and lower extremities and all joints. 

Neurologic . Mental Status. Conscious, active and not irritable Cranial Nerves: o I—cannot be assessed

o o o o o o o o o

II- Can see in all four quadrants of the visual fields II, III— pupils briskly reactive to light, with blink reflex III, IV, VI— Full extraocular movement, eyes move together V motor—jaw movement is intact VII motor— symmetrical facial expressions VIII—responds to sounds IX, X—able to swallow XI—able to move the neck from side to side XII—tongue midline

Reflexes: o (-) palmar grasp : disappears at 3–4 months o (+) plantar grasp : disappears at 8–10 months o (-) rooting : disappears by 3–4 months o (-) tonic neck : disappears by 4–6 months o (+)Babinski: disappears within 2 years

Growth Chart