CLINICAL EXAMINATION

IN NEONATES
Yurita Handoyo dr., SpA
FACULTY OF MEDICINE
U P N VETERAN

CLINICAL EXAMINATION
IN THE NEONATES
I. HISTORY
II. PHYSICAL EXAMINATION
I. History
* Chief complaint
* Complaint description
* Maternal Pregnancy: prenatal care
duration of pregnancy
Familial history
General health
* Birth history : onset & events of labor
amniotic fluid
* Neonatal history : timing of umbilical cord
clamping
* Family History - Additional history
II. Physical examination
* Normal Baby done at least 3 times:
- After delivery
- at 12 hours of age
- at discharge

* Examination at the Delivery Room

* Examination at the Neonatal Room
Physical examination at the
Delivery Room
General examination
* General condition
* To rule out major anomalies


For high risk baby
* Cardiorespiratory system - metabolic
* Detail examination : in 24 h after stabilization

Physical examination at the
Delivery Room

APGAR score
Placenta
Umbilical
Birth trauma
Congenital anomalies
Nasal and gastric catheterization
Color : Cyanotic, pale,reddish pink


Sign Score = 0 Score = 1 Score = 2
----------------------------------------------------------------------------------------------------
APPEARANCE Blue all over, Acrocyanosis Pink all over
(color) or pale

PULSE Absent Below 100 Above 100
(heart rate)

GRIMACE No response Grimace or Good cry
(reflex irritability) weak cry

ACTIVITY Flaccid Some flexion of Well flexed, or active
(muscle tone) extremities movements of extremities

RESPIRATIONS Absent Weak, irregular, Good crying
or gasping

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The APGAR score should be assigned at one minute and five minutes, finding the
total score (0-10) at each time by adding up points from the table above.
Continue to assign scores every five minutes thereafter as long as the APGAR
score is less than 7.
Physical examination at the Delivery Room
APGAR Scores
Prechtl and Beintema (1964)

State 1 : Eyes closed, regular respiration,
no movement
State 2 : Eyes closed, irregular respiration,
no gross movements
State 3 : Eyes open, no gross movements
State 4 : Eyes open, gross movements,
no crying
State 5 : Eyes open or closed, crying
Physical examination at the Delivery Room
Grading of state
Brazelton (1973)
State 1 : Deep sleep with regular breathing, eyes closed,
no spontaneous activity, no eye-movements
State 2 : Light sleep with eyes closed;
rapid eye-movements , irregular respiration
State 3 : Drowsy or semi-dozing; eyes open or closed,
activity variable, movements usually smooth
State 4 : Alert, with bright look; minimal motor activity
State 5 : Eyes open, considerable motor activity
State 6 : Crying
Physical examination at the Delivery Room
Grading of state
Physical Examination At The
Neonatology Room
The first 12 hours after birth
The mother, and, if possible, the father
should be present
The infant is unclothed under a radiant
warmer
Auscultation (heart & lung) and abdomninal
palpable
Vital sign :
Rate of resp. and heart rate, temperature,
blood pressure

Physical Examination At The
Neonatology Room
General Appearance
Head
Neck
Thorax
Facial Appearance
Respiratory- Cardiovascular
Neurology examination
Physical Examination At The Neonatology Room
General appearance
Symmetry
Face
Gestational age
Skin : color and texture, scratch marks,
rash
Neuromuscular : motion, respons, tone.
Breech
presentation
Hydrocephalus
Feto-fetal
tranfusion
syndrome
Bronze baby
syndrome
Growth retardation
Discordant twins
Harlequin
Cytomegalovirus
Multiple purpura
Hepatosplenomegaly
Cranial CT scan
- Hydrocephalus
- Periventricular calcification
Physical Examination At The Neonatology Room
THE CRY
Husky
Loud
Sustained
Physical Examination At The Neonatology Room
Skin
Vernix caseosa
Lanugo
Milia
Mongolian spots
Erythema toxicum
Hemangioma
Birth trauma
Color : pale, icterus, cyanosis, plethora,
cutis marmorata
Cutis marmorata
Miliaria
Physical Examination At The Neonatology Room
Head
Shape
Circumference
Scalp
Caput succedaneum
Cephalhaematoma
Suture lines
Fontanelles
Birth Trauma
Laseration post VE Laseration post SC
Cephalohematoma
Caput succedaneum
Facial Appearance
Pre term baby Post term baby
SGA
Infant of diabetic
mother : macrosomia
Facial Appearance
Physical Examination At The Neonatology Room
Eyes

- Scleral hemorrhage
- Icterus
- Exudate
- Pupillarry size
- Cataract

Physical Examination At The Neonatology Room
Ears

Position
Shape
Auditory canals
28 weeks
gestation :
little cartilago,
pliable
36 weeks to term
gestation : firm ear,
well-formed margin
Hypoplastic auricle
Low-set ear
Microtia
Physical Examination At The Neonatology Room
Mouth & Lower Face
Symmetri
Size
Cleft (Labio-palatoschizis)
Teeth
Ranula
Cyst (Epstein,s pearls)
Oral thrush
Oral thrush
Labio-
palatoschizis
True teeth with roots
Macroglossia
Physical Examination At The Neonatology Room
Neck

Symmetry
Range of motion
Thyroid gland
Severe shortness
Goiter :
iodine deficiency
Ectopic thyroid
Chest & Lung

Symmetry
Pectus excavatum
Nipples
Auscultation
Nipple
28 weeks gestation :
No breast tissue, areola barely visible
32 weeks gestation :
visible areola, little
breast tissue
36 weeks gestation :
well-defined areola,
breast nodule
Physical Examination At The Neonatology Room
Respiratory - Cardiovascular

- Rate
- Rhythm
- Apnea
- Retraction
- Grunting

- Position
- Rate
- Rhythm
- Murmurs

RESPIRATION HEART
Duktus
Arteriosus
Physical Examination At The Neonatology Room
Auscultation
Physical Examination At The Neonatology Room
Abdomen
Inspecting :
- Movement patterns
- omphalocele, gastroschisis
- Shape (scaphoid, distended)
- Umbilical cord
Auskultation : bowel sounds
Palpation :
- Liver edge is felt 1-2 cm below
the right costal margin at the
midclav line
- Normally; spleen not felt

Umbilical cord
Umbilical hernia
Omphalocele
Physical Examination At The Neonatology Room
Genital System

- Scrotum
- Hydroceles
- Testes
- Length of
penis
- Phimosis
- Hypospadia /
Epispadia

- Labia majora
- Mucosal tag
-Vaginal
discharge


MALE
FEMALE
Genitalia - Male
28 weeks gestation :
testis high in scrotum
36 weeks to term
gestation : testis well
descended, increased
scrotal pigmentation
Micropenis
Undescensus testis
Ambiguous genitalia
Male (XY)
Testes in labioscrotal
folds-androgen
insentivity
Female (XX)
Clitoral enlargement
Physical Examination At The Neonatology Room
Musculo Sceletal System

- Patency
- Size
- Position
- Fistulae

Anus

Anomalies of digit
Club feet
Hip dislocation Ortholani Manuver
Plantar creases

Extremities
Physical Examination At The Neonatology Room
Musculo Sceletal System
Anal sphincter absent
Dermatitis
Rectovaginal fistula
Thumb
hypoplasia
Polydactily
Sindactily
Foot sole creases
32 weeks gestation :
creases in anterior
one third
36 weeks to term gestation :
creases over the majority of
the sole
Post-Term
Long nails, peeling skin
Simian crease
Clubbing of fingers
Sepsis
SCLEREMA
Talipes equinovarus
Physical Examination At The Neonatology Room
Neurologic examination
Symmetry of movement
Muscle tone : hypo/hypertoni
Reflex : Grasp, Moro, Rooting
Cranial nerve
Peripheral nerve :
- Erb-Duchenne paralysis
- Klumpkes paralysis
GESTATIONAL AGE



Reflex
Plantar grasp Reflex
Grasp
Reflex
Rooting Reflex
Moro Reflex
Paralysis
Seventh nerve palsy ;
unilateral facial
paralysis
Erb palsy
Symmetry
Scoliosis
Kyphosis
Meningocele
Myelocele
Spine
Meningocel
Meningoensephalocele