Review of Neonatal History Taking and Physical Examination

- Special examination
- < 1 month; 28 days old; < 28 days old
- With Chief complaint related to maternal history

I. GENERAL DATA
a. Name
b. Age
c. Date of birth
d. Address
e. Religion
f. Informant
II. CHIEF COMPLAINT
III. MATERNAL HISTORY AND BIRTH HISTORY
a. Chronic Illness
i. Hypertension
ii. Diabetes Mellitus
iii. Systemic Lupus Erythematosus
b. Infections
i. STD
ii. Viral
1. Congenital Rubella
2. Congenital Varicella
iii. Drugs/ Medications
iv. Labor and Delivery
1. Duration
2. Difficulty: Shoulder dystocia
IV. NEONATAL HISTORY
a. History of Illness
b. State according to Age
V. FEEDING
VI. DEVELOPMENTAL HISTORY
VII. IMMUNIZATION (ACCORDING TO AGE OF PATIENT)
VIII. FAMILY HISTORY
IX. SOCIOECONOMIC HISTORY
X. ENVIRONMENTAL HISTORY
 PHYSICAL EXAMINATION

- Should be done in:

o IN delivery room: Immediately after birth
o IN nursery or rooming-in area within 12 hours of birth
o Upon discharge, preferably in presence of mother
- Determine any congenital anomalies
- Transition from fetal to extra-uterine life
- Effects of Labor, delivery, anesthesias
- Signs of infection or metabolic disease
- Approach depends on the situation

I. GENERAL APPEARANCE
o Should be examined: NAKED
 Posture
 Color
 Activity
 Muscle tone
 Gross congenital abnormalities
 APGAR
II. VITAL SIGNS
o Should be monitored every 30 minutes from birth to 2 hours or
until stable
 Temperature
• Indicate if
o Rectum
o Axilla
 Respirations
• 40-60 cycles/ min (Sombilla/ Nafarette, etc)
• 30-60 cycles/ min (Nelsons)
• Periodic breathing
 Cardiac Rate
• 120-160 bpm
• Changes with infant’s activity
• Increased:
o CNS Irritability
o CHF
o Sepsis
o Anemia
o Fever
  Blood pressure
• Not routinely done
• Width: 2/3 length of upper arm
• Special care: Coarctation of Aorta (in all
extremities)
• Preterm: 55-75/ 35-45
• Fullterm: 65-85/ 45- 55
III. ANTHROPOMETRIC
a. Weight/ Percentiles
i. SGA
 Symmetric
• Brain corresponds with body size
• Onset early in gestation
• Environmental, genetics, chromosomal disorders,
intrauterine infections and metabolic disorders
 Asymmetric
• Onset is late in gestations
• No or minimal effects in brain growth
• Uteroplacental insiffciency with chronic hypoxia
ii. AGA
iii. LGA
• Increased risk of asphyxia, birth injuries, RDS,
hypoglycaemia
b. Length/ Percentiles
c. Head Circumference
• Occipito-frontal circumference
• 32-36 cm (14 inches)
d. Chest circumference
• Nipple line
IV. SKIN
a. Color
i. Plethora
• Deep rosy red
o Polycythemia
o Overoxygenated
o Overheated
ii. Jaundice
• Hyperbilirubinemia
iii. Pallor
• Anemia
 • Birth asphyxia
• Shock
• PDA
iv. Cyanosis
• Central
o Low O2 sat
• Acrocyanosis
o Vasomotor instability
b. Mottling
 Cold stress, hypovolemia, sepsis
 Cutis marmorata
• Down Syndrome
• Trisomy 18, 13
c. Vernix Caseosa
 Greasy white substance
 Moisture barrier
d. Rashes/ Birthmarks
 Milia
• Whitish pinhead size
• Usually seen in Chin, nose
 Erythema toxicum
• Red lesions with white papule in center
 Miliara Crystalluria
• Pinpoint clear residue which may empty
 Transient Pustular
• Self-limited, whitish
 Macular hemangioa
• Stork bites
• True vascular nevus seen in occipital area, eyelids,
glabella
• Disappear within 1st year of life
 Port wine stain
 Mongolian Spots
• Blue
• Sacrum
V. HEAD
 Shape, cuts, bruises
• Microcephaly
o Less than 3SD, below mean
o Familial, infections, trisomies
 • Macrocephaly
o Greater 2 SD above mean
o Hydrocephalus, Skeletal d/o
 Fontanels
o Anterior Fontanel
 Diamond
 9-18 months closes
 Large: Hydrocephalus
 Small: Craniosyntoses
o Posterior Fontanel
 Triangular
 4-6 weeks closes (2-3 months)
 Congenital hypothyroidism
 Hydrocephalus
 Molding
• Passage to birth canal
• Resolves after few days

Caput Succedaneum Cephalhematoma

Not well demarcated Demarcated
Crosses suture lines Doesn’t cross suture lines
Discolorization No discolorization
No rupture Rupture of vessels
Recovery: days to weeks Weeks to months
Both self-limiting

VI. FACE
i. Abnormalities
1. Hypertelorism
2. Low set ears
ii. Congenital anomalies
iii. Facial nerve palsy
1. Forces delivery
VII. EYES
a. ROR
i. Cataracts
• White pupillary reflex
• Leukoplakia
b. Subconjunctical haemorrhage
• Benign
 • Resolves within 2 weeks
VIII. NOSE
i. Shape
ii. Size
iii. Patency
IX. EARS
i. Shape
ii. Size
iii. Position
iv. Tags
X. MOUTH
i. Cleft lip/ palate
ii. Epstein pearls
• Located at hard/ soft palate which resolves
spontaneously
iii. Mucocele
• Small lesion at oral mucosa
• Due to trauma to salivary gland ducts
• Resolves spontaneously
iv. Natal teeth
v. Macroglossia
• Beckwith’s syndrome
• Congenital hypothyroidism
XI. NECK
i.
Thyroglossal duct cysts
ii.
Hematoma
iii.
Cystic Hygromas
iv.Congenital anomalies
• Webbed
v. Clavicular fracture
• Most common fracture
• Large infants
• Deformity, crepitus, irregularity
• Tx: Splint/ Immobilize
XII. CHEST
i. Symmetry of Chest
• Tachypnea
• Retractions
• Barrel chest
ii. Abdominal
 • Quiet breathing
iii. Breasts
• 1 cm
• Witch’s milk
• Supernumerary nipples
• Extra nipples
iv. Breath sounds
• Bronchial breath sounds
• Absent/ decreased
o Pneumothorax
o Atelectasis
o Diaphragmatic hernia
XIII. HEART
i. Precordial activity
ii. Rate, rhythm, quality
iii. Murmurs
• Flow murmurs
iv. Increase with stimulation
v. Serum electrolytes and ECG to rule out Heart Block and SLE
XIV. ABDOMEN
i. Soft, globular
ii. Defects
1. Omphalocele
2. Gastroschisis
3. Congenital Diaphragmatic Hernia (scaphoid shape)
iii. Bowel sounds
iv. Distention, Masses (Necrotizing enterocolitis)
v. Umbilicus
• Stump (foul smelling)
• Discharges
• Redness

XV. GENITALIA
i. Males
• Penis > 2cm
• Hydrocele, hypospadias, epispadias
• Chordee
• Phimosis
• Testis
ii. Females
 • Labia, Clitoris, Vaginal opening
• Redundant hymenal tissues/ tags
• Vaginal discharges
o Pseudomenses (estrogen withdrawal)
• Clitoromegaly
o Masculinization
o Virilising tumor
o CAH
• Ambiguous Genitalia
o Emergency
XVI. HIPS
i. Congenital hip disclocation
1. Ortolani
2. Barlow
ii. Clicking sounds: pathologic
XVII. EXTREMITIES
 Arms, legs, digit pulse
 Syndactyly
• Abnormal fusion
 Polydactyly
• Supernumerary digits
 Simian crease
• Down Syndrome (palms)
 Talipes equinavarus
• Clubfoot
 Metatarsu Varus
• Adduction of forefoot
XVIII. TRUNK AND SPINE
i. Gross defects
ii. Tufts of hair
• Spina bifida oculta
iii. Sacral dimple
• Meningocele
XIX. ANUS/ RECTUM
i. Patency
• Imperforate anus
• Meconium should be passed with 24-48 hours of
birth
XX. NERVOUS SYSTEM
i. Assessment of state
ii. Spontaneous muscle activity
 iii. Passive/ Active

PRIMITIVE REFLEXES
-Absence or presence beyond a specified time leads to dysfunction
of the CNS

Reflex Onset Duration

Palmar grasp 28 wks 2-3 mos (1-2)
Rooting 32 wks 1 mo
Moro 28-32 wks 5-6 mos (4-5)
Tonic neck 35 wks 6-7 mos
Parachute reflex 7-8 mos Remains