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Normal Newborn Infant Physical Exam

GENERAL: A well-developed infant in no acute respiratory distress.
VITAL SIGNS: Initial temperature was XX, pulse XX, respirations XX. Weight XX grams, length XX cm, head circumference XX cm.
HEENT: Head is normocephalic with anterior fontanelle open, soft, and non-bulging. Eyes: Red reflex elicited bilaterally. TMs occluded with vernix and not well visualized. Nose and throat are patent without palatal defect.
NECK: Supple without clavicular fracture.
LUNGS: Clear to auscultation.
HEART: Regular rate without murmur, click, or gallop present. Pulses are 2/4 for brachial and femoral.
ABDOMEN: Soft with bowel sounds present. No masses or organomegaly.
EXTREMITIES: Without evidence of hip defects.
NEUROLOGIC: The infant has good Moro, grasp, and suck reflexes.
SKIN: Warm and dry without evidence of rash.

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