Normal PEDs PE

Posted on by tydotphrase

Pediatric Physical Exam
General- in NAD
Head: atraumatic, normocephalic
Eyes: no icterus, no discharge, no conjunctivitis
Ears: no discharge, tympanic membranes nml bilat
Nose: no discharge, moist nasal mucosa
Throat: moist oral mucosa, no exudates, uvula midline
Neck: no lymphadenopathy, no nuchal rigidity
CV- RRR, nml S1, S2 w no murmurs
Respiratory- CTAB, no wheezing or crackles
Abdomen- Soft, NTND, no rigidity, no rebound, no guarding,
Extremities- warm, symmetric tone, nml muscle development and strength
Skin- moist; without rash or erythema

Infant Physical Exam
General: alert, no apparent distress
Skin: no lesions, no jaundice
Head/Fontanelles: normocephalic, AF soft and flat
EENT: conjunctiva clear, nares patent, normal oral mucosa, ears normal placement, TM’s pearly
Neck: full range of motion
Lungs:  clear bilaterally
CV: normal S1, S2, RRR without murmur normal femoral pulses
Abdomen: soft, no hepatosplenomegaly or masses symmetric
Extremities: no deformities
Hips: negative Barlow/Ortolani, > 60° abduction
Genitourinary: normal external genitalia
Neurologic: moves all extremities symmetrically, normal tone, responds to clap, positive moro, grasp/suck/root/toe grasp

  • Appropriate tone. Pt is interactive and consolable. Gaze and speech/cry are appropriate

ROS: 12 point ROS Negative except as above.

 

WCC 2weeks HPI

No complications with the pregnancy or delivery. Vaginal delivery. No known hereditary medical problems.

Mother has no baby blues and feels she has proper support for each day. Thinks things are going well.

Feeding: Pt breast feeds every hours
Sleeping: hours during day and hours during night
Voiding: baby pees and poops normally. wet diapers per day. stool diapers per day.
Development: Baby makes eye contact, has appropriate tone and responds to voice
No one smokes in the home. Baby is in car seat always when driving. Mother knows how to take temperature. Water heater is set to 120F max and smoke alarms are checked regularly.

2 thoughts on “Normal PEDs PE”

  1. This is my favorite physical exam template. I call it a “no touch” physical exam template. If you went into the room to see the patient and shake his/her hand you can capture all of the following. Has nine organ/systems required to code/bill for a comprehensive exam.

    General: No acute distress. Awake and conversant.
    Eyes: Normal conjunctiva, anicteric. Round symmetric pupils.
    ENT: Hearing grossly intact. No nasal discharge.
    Neck: Neck is supple. No masses or thyromegaly.
    Respiratory: Respirations are non-labored. No wheezing.
    Skin: Warm. No rashes or ulcers.
    Psych: Alert and oriented. Cooperative, Appropriate mood and affect, Normal judgment.
    CV: No lower extremity edema.
    MSK: Normal ambulation. No clubbing or cyanosis.
    Neuro: Sensation and CN II-XII grossly normal.

    from https://www.statnote.com

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