Physical Examination of Pre-term Baby

Physical Examination

Head to Toe Assessment

Baby E.P. is conscious, with inactive behavior. His body is symmetrical, in good proportion but with minimal movements. He weighs 2.1 kg, stands 42 cm and measures 31 cm (Head Circumference), 27 cm (Chest Circumference) and 25cm (Abdominal Circumference). His initial vital signs are: 35.2° C for the temperature, 120 bpm HR, 27 bpm RR, and 46 mmHg for the systolic BP. His skin is thin, smooth, shiny, a bit ruddy, and acrocyanotic in complexion. Small blood vessels are visible in the peripheral area. Vernix caseosa is visible in the arms, legs and thighs. Milia are also present as well as some patches of lanugo on the shoulders and back. His nails are short, purplish, convex and smooth. His head is soft, round, and symmetrical. The Posterior and Anterior Fontanelles are present upon palpation with overlapping of the anterior fontanelle. Hair is smooth with fine texture. Face is symmetric with normal eyebrows and eyelashes. Eyes are symmetrical, on the same level, shut, and edematous. Blink reflex is present. Cornea is clear. Sclera appears bluish to white. Pupils are equal in size, round and react to light by accommodation. Lashes are absent. Nose is small, narrow in midline, and in even replacement in relationship to eyes and mouth. Nares are patent bilaterally. Nasal flaring is visible. Mouth is symmetrical. Gag reflex is present with difficulty in sucking and swallowing. Hard palate is dome shaped. Uvula is in midline with symmetrical movement of soft palate. Palate is intact. Epithelial pears are present in the mucosa. Esophagus is patent. Tongue pink, rough in texture, noncoated, freely moves in all directions and is in midline. Ears are symmetrical, soft, slightly curved pinna and with semi-flexible cartilages. Ears are clear of any lesions, cysts or nodules. There is no presence of discharge in the canals. The pinna appears larger than his head. He appears to listen to sound or noise. He elicits Moro reflex. Neck is short, straight, creased with skin folds. The clavicles are intact. The shoulders are symmetric. The chest appears normal in shape without depressed or prominent sternum. There is unequal chest expansion when breathing. There are intercostal, subcostal and supracostal retractions due to RDS. Breath sounds are prominent accompanied by adventitious sounds. Breasts are flat, lacking breast tissue. Areola is not well developed. The heart lies horizontally with the left border extending to left of mid-clavicle upon auscultation. The heart is regular in rhythm and in rate. There are noticeable murmurs but no thrills. The abdomen is cylindrical with some protrusion, appears large in relation to pelvis, and the muscles are lax. The umbilicus is bluish white in color. Two arteries and one vein are apparent in the umbilicus but no bleeding. Soft bowel sounds are heard but decreased. Pulses in the femoral area are palpable. The male genital has minimal presence of rugae and the testes are positioned in the upper inguinal canal. Buttocks are symmetric, patent and without fissures, tears or skin tags. There are no imminent creases on the sole of the feet. Extremities are limp and remained extended. The arms are equal in length, with bilateral movement and slightly flexed. There is normal number of fingers. Nails are present but short. There is no sign of hip instability. Legs are equal in length. Foot is in straight line but few, underdeveloped creases. He has poor body tone, insufficient body fat and weak cry.