Heent

Anterior fontanelle tense and bulging. Hair scant.

Sclera white, conjunctiva pink; red reflex present.

External ear canals patent; tympanic membranes pearly gray, with good cone of light.

Nasal mucosa pink.

Oral mucosa moist and pink. Pharynx without exudates.

Neck

Trachea midline, neck without thyromegaly

Lymph nodes

No cervical, axillary, epitrochlear, or inguinal adenopathy

Thorax and lungs

Thorax symmetric with good expansion; no use of accessory muscles of respiration, although patient is crying.

Lungs with transmitted crying sounds. Breath sounds vesicular; no rales, wheezes, or rhonchi.

Cardiovascular

Good S1, S2; no S3, S4; no murmurs, or extra sounds

Abdomen

Protuberant with active bowel sounds. Umbilicus clean, dry, and intact.

Soft, nontender, nondistended, no masses or hepatosplenomegaly.

Peripheral vascular/ extremities

Capillary refill delayed to 5 seconds. Femoral pulses 2+. No femoral or abdominal bruits.

Female genitalia

No inguinal adenopathy. External genitalia without erythema or lesions; no lesions or masses.

Musculoskeletal

Spine intact, no dimpling, no tufts of hair, no skin opening

Neurologic

Difficult to appreciate nuchal rigidity

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