Physical Examination:

I. General Survey:
Alert, good posture and gait. well nourished, not in cardiopulmonary distress, urinates 4 times
a day usually clear urine, capillary refill time of less than 2 seconds.

II. Vital Signs and Measurements:

Temperature of 36.7 C, pulse rate of 113 bpm, respiratory rate of 20 bpm, head
circumference of 18 inches, abdominal circumference of 17.1 inches, chest circumference:
17.5 inches, weight is 24 kg, height of 32.5 inches, arm span of 31.5 inches.

III. Skin:
No pallor, no cyanosis, no jaundice, no birthmarks aside from diaper rash on the buttocks
area no other lesions seen, no masses, no tenderness, good skin turgor and elasticity.

IV. HEENT:
A. Head: Normocephalic, fontanels closed, no tenderness, no masses, no lesions, hair is color
black , fine, and smooth in texture.Face is symmetrical with no visible deformities and no
lesions.

B. Eyes : Eyebrow is black and well-distributed. There is no ptosis, strabismus and retraction
noted. Eyelashes also black and are directed outwards and longer on the upper eyelid
than the lower eyelid. Periorbital area is not swollen nor has hematoma. Sclera is white
with no lesions; cornea is transparent with no opacities, no ulceration, and no any other
lesions; iris is round and brown in color; pupil is symmetrical and fixed dilated with direct
consensual light reflex; and lenses are both transparent with no opacities noted. No gross
defects in visual fields and there is no tension noted upon palpation of the eyeball. With
positive red light reflex.

C. Ears: Ears are symmetrical and with no lesions. The right pinna is slightly protruded
inward. There is no tenderness noted on the pinna and mastoid area. External auditory
canal is patent pink with no notable discharge and foreign bodies. But with some scanty
dry cerumen. Tympanic membrane is pearly white in color with good cone of light, no
bulging, no retraction, and no perforation noted.
D. Nose: Nose is symmetrical with no flaring noted; no polyps, vestibule is patent pink and
has some clear secretions but no bleeding points; septum is intact and at the midline.
There is no tenderness noted in the paranasal sinuses upon palpation and no clouding
noted upon trans-illumination test.

E. Mouth and Throat: Lips are pink, symmetrical, moist, with no notable lesions; tongue is
pink, intact, at the midline, and has no difficulty in mobility; dental carries are present on
the front teeth and some on the molars, palate is pink with no notable lesions; uvula is at
the midline; tonsils are pink and not inflamed; there are no other notable enlargements,
no lesions, and no swellings on the surfaces of the oral mucosa.
F. Neck: is symmetrical with no notable gross deformities, brown-colored skin, no visible
subcutaneous blood vessels, and has a normal muscle development, no palpable lymph
nodes and no nuchal rigidity.

V. Lungs and Thorax

The thorax is elliptical with no visible deformities, no visible subcutaneous blood vessels and
has a normal muscle development. Respiratory rate is 20 breaths per minute with normal
depth and rhythm, no bulging, and no chest lagging. Inspiration is effortless and has
symmetrical chest expansion. There are no tenderness and masses noted upon palpation. On
auscultation no rales, no crackles, no wheezes, no rhonchi, and no stridor.

VI. Cardiovascular System

There is no bulging or depression of the thorax, with adynamic precordium, without visible
pulsations in supine position. No neck vein distention. No murmurs and no bruit heard.
Normal quality of heart sounds. Carotid, femoral, brachial, popliteal, dorsalis pedis and radial
arteries are palpable, strong and bilaterally equal.

VII. Abdomen
Protuberant in shape, umbilicus is dry, no hernia, with good muscle tone, 12 bowel sounds
per minute which is normal, upon percussion generally tympanitic, and on palpation no
masses and no tenderness.

VIII. Genito-urinary tract

Not yet circumcised according to the mother and she requested we don’t remove the diaper
since she didn’t bring an extra one.

IX. MusculoskeletaL System

Overall has normal posture and gait, no observable deformities. No scoliosis, no kyphosis, no
lordosis. The joints have noo swelling, no tenderness. No deformities in the extremities, no
edema, and are symmetrical. No hip dislocation. And overall has no limitations in the range
of motion.

X. Neurologic System
No abnormalities in motor division, no paresis, no paralysis, no spasms, no rigidity, no tics, no
tremors, no clonus. Cranial nerves intact. Reflexes are normal and present. Sensory division
also intact. And cerebellar division normal , no ataxia, no incoordination, no nystagmus, and
no dysdiachokinesia.