OBJECTIVE:
– VITALS: _
– WEIGHTS: BW _. Today’s weight _.
– GEN: Normal general appearance. NAD.
– HEAD: NCAT. No cephalohematoma. AFOSF.
– EENT: Red reflex present bilaterally. Normal ext ears, nose, lips.
– MOUTH: MMM. Normal gums, mucosa, palate, OP.
– NECK: Supple.
– CV: RRR, no m/r/g. Normal femoral pulses.
– LUNGS: CTAB, no w/r/c.
– ABD: Soft, NT/ND, NBS, no masses or organomegaly. Normal umbilical stump without surrounding erythema. Anus & perineum normal. No hernias.
– GU: Normal _male genitalia. Testes descended bilaterally.
– SKIN: WWP. No jaundice, new skin rashes, or abnormal lesions. No sacral dimple.
– MSK: Normal extremities & spine. No hip clicks or clunks. No clavicular fracture.
– NEURO: MAE symmetrically. Normal moro & suck reflexes. Normal muscle tone.
