PE

PE – Infant Basic

Peds

General Appearance: alert, no apparent distress, appropriately interactive with examiner
Skin: no lesions, no jaundice
Head/Fontanelles: normocephalic, AF_____x_______,  RR normal bilaterally
EENT: conjunctiva clear, nares patent, normal oral mucosa, ears normal placement, TM’s clear bilaterally
Neck: full range of motion
Lungs:  CTA bilaterally, no adventitious breath sounds
CV: normal S1, S2, RRR without murmur normal femoral pulses
Abdomen: soft, no hepatosplenomegaly or masses
Extremities: no deformities
Hips: negative Barlow/Ortolani, > 60° abduction
Genitourinary: Male: testes descended, circ/uncirc    //  Female: normal external genitalia
Neurologic: moves all extremities symmetrically, normal tone, responds to clap, positive moro, grasp/suck/root/toe grasp

PE – Basic

Physical Exam
GENERAL APPEARANCE:  AxOx4, generally well-appearing ***M/F, no acute distress.
HEENT:  NC, AT. MMM. EOMI, clear conjunctiva, oropharynx clear.
NECK:  Supple without lymphadenopathy.  No stiffness or restricted ROM.
HEART:  Normal rate and regular rhythm, normal S1/S1, no m/r/g
LUNGS:  CTAB, moving air well. No crackles or wheezes are heard.
ABDOMEN:  Soft, nontender, nondistended with good bowel sounds heard.
BACK: No CVAT, no obvious deformity.
EXTREMITIES:  Without cyanosis, clubbing or edema.
NEUROLOGICAL:  Grossly nonfocal. Alert and oriented, moving all 4 extremities. CN not formally tested but appear grossly intact. Observed to ambulate with normal gait.
Skin:  Warm and dry without any rash.