report of integumentary examination of neonate of 4 days old
Date of Examination: [Insert Date of Examination]
Patient Name: [Insert Name of Neonate]
Age: 4 days old
Sex: [Insert Sex of Neonate]
Medical Record Number: [Insert Medical Record Number]
Chief Complaint:
The patient does not have any specific complaints as the examination is being conducted as part of a routine neonatal check-up.
History:
The patient was born via uncomplicated l delivery at [Insert Name of Hospital] on [Insert Date of Birth]. The neonate is currently breastfeeding and has been passing urine and meconium stool regularly.
Physical Examination:
1. Skin:
- The skin is pink in color.
- No lesions, rashes, or discoloration noted.
- Turgor is good.
- No signs of bruising or trauma.
- Lanugo hair present on the body.
2. Hair:
- Sparse, fine hair present on the scalp.
3. Nails:
- Nails appear pink and well-formed.
4. Subcutaneous Tissue:
- Adequate subcutaneous tissue present.
5. Temperature:
- Axillary temperature within normal limits.
6. Fontanelles:
- Anterior and posterior fontanelles soft and flat.
7. Eyes:
- Eyes appear symmetrical with equal pupils.
- No discharge or redness noted.
- Able to open and close eyes appropriately.
8. Ears:
- Ears set symmetrically on the head.
- No deformities or discharge noted.
9. Nose:
- Nares patent.
- No nasal discharge or flaring of nostrils.
10. Mouth:
- Lips appear pink and moist.
- No cleft lip or palate noted.
- Able to suck and swallow without difficulty.
11. Neck:
- No masses or swelling noted.
- Neck movements appear normal.
Assessment:
Overall, the integumentary examination of the 4-day-old neonate appears normal with no significant findings. The skin, hair, nails, and mucous membranes are all within normal limits.
Plan:
- Continue to monitor the neonate's skin for any changes or abnormalities.
- Schedule a follow-up visit for routine neonatal care and vaccinations.
- Educate parents on proper skin care and hygiene for the newborn.
Provider Signature: [Insert Signature]
Date: [Insert Date]