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Neonatal Ward Admission: History & Examination Template

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NEONATAL WARD ADMISSION PROFORMA

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INSTITUTION: ___________________________   WARD: ___________________
DATE OF ADMISSION: ___________________   TIME: ___________________
MRN / File No.: _______________________   Admitted by: _____________

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SECTION 1 — PATIENT IDENTIFICATION

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SECTION 2 — PRESENTING COMPLAINT

Chief reason for admission (in caregiver's words):
_________________________________________________________________
Duration: _______________

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SECTION 3 — MATERNAL HISTORY

"Gathering a complete maternal history, including a review of the mother's medical problems; past obstetric history; medications, drug, alcohol, or tobacco use during pregnancy; and prenatal serologies is important." — Textbook of Family Medicine 9e, p. 529

3A. Antenatal History

3B. Previous Obstetric History

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SECTION 4 — INTRAPARTUM HISTORY

"Obtain a brief history from the mother, including gestational age, number of fetuses, history of diabetes, hypertension, prolonged rupture of membranes, fever, and meconium-stained amniotic fluid." — Tintinalli's Emergency Medicine, p. 716

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SECTION 5 — NEONATAL BIRTH HISTORY

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SECTION 6 — POSTNATAL HISTORY (for admissions after day 1)

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SECTION 7 — FAMILY & SOCIAL HISTORY

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SECTION 8 — PHYSICAL EXAMINATION

"The examination is best performed if the infant is quietly resting and should begin with an assessment of the infant's general appearance followed by auscultation of the heart and lungs. The examination should then proceed from head to toe in a systematic fashion." — Textbook of Family Medicine 9e, p. 529

8A. Anthropometry & Vital Signs

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8B. General Appearance

☐ Active / vigorous    ☐ Lethargic    ☐ Irritable    ☐ Inconsolable cry
☐ Comfortable at rest  ☐ Respiratory distress

Color:
☐ Pink (normal)   ☐ Pallor   ☐ Jaundice   ☐ Central cyanosis
☐ Acrocyanosis (peripheral — may be normal in first hrs)
☐ Plethoric / ruddy   ☐ Mottled

Tone:
☐ Normal (extremities flexed, symmetric)   ☐ Hypotonic (frog-leg posture)
☐ Hypertonic / rigid   ☐ Asymmetric

Nutritional status:
☐ Well-nourished   ☐ Thin/malnourished   ☐ Oedematous

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8C. Head & Skull

Shape: ☐ Normal   ☐ Microcephaly   ☐ Macrocephaly   ☐ Asymmetric
       ☐ Molding (overriding sutures — common, resolves in days)
       ☐ Craniosynostosis (persistent asymmetry — refer)

Anterior fontanel: ☐ Soft/flat (normal)   ☐ Bulging (↑ICP)   ☐ Sunken (dehydration)
  Size: ______ × ______ cm (normal: 4–6 cm diameter)

Posterior fontanel: ☐ Open (<1 cm, normal)   ☐ Closed   ☐ Enlarged

Scalp:
☐ Normal   ☐ Caput succedaneum (crosses sutures, resolves in days)
☐ Cephalohematoma (does NOT cross sutures, resolves in weeks–months)
☐ Subgaleal hematoma (fluctuant, crosses sutures — URGENT)
☐ Scalp lacerations / electrode marks

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8D. Eyes

Spacing: ☐ Normal   ☐ Hypertelorism   ☐ Hypotelorism
Symmetry: ☐ Symmetric   ☐ Asymmetric
Pupils: ☐ Equal & reactive   ☐ Unequal (anisocoria)
Red reflex: ☐ Present bilaterally (NORMAL)   ☐ White reflex — REFER (retinoblastoma/cataract/retinal detachment)
Sclera: ☐ White   ☐ Icteric   ☐ Haemorrhage (subconjunctival — birth trauma, benign)
Discharge: ☐ None   ☐ Purulent (ophthalmia neonatorum — URGENT)   ☐ Watery (dacryostenosis)
Eyelids: ☐ Normal   ☐ Ptosis   ☐ Coloboma

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8E. Ears, Nose & Throat

Ears:
☐ Normal position and morphology
☐ Low-set ears (Turner, Down, renal anomaly)
☐ Pre-auricular skin tag / pit
☐ Ear canal patent bilaterally

Nose:
☐ Patent both nares (test: occlude one at a time)
☐ Choanal atresia suspected (respiratory distress relieved by crying)
☐ Nasal flaring (respiratory distress)

Mouth:
Palate: ☐ Intact   ☐ Cleft palate   ☐ Cleft lip
        ☐ Submucosal cleft (palpate midline)
Tongue: ☐ Normal   ☐ Macroglossia   ☐ Tongue-tie (ankyloglossia)
Teeth: ☐ None (normal)   ☐ Natal teeth
Gums: ☐ Normal   ☐ Epstein's pearls (benign keratin cysts)
Oral mucosa: ☐ Normal   ☐ Thrush (white plaques)
Throat: ☐ Not examined   ☐ Normal

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8F. Neck

☐ No masses   ☐ Webbing (Turner syndrome)
☐ Cystic hygroma   ☐ Goitre   ☐ Sternocleidomastoid mass (torticollis)
☐ Clavicle fracture (birth trauma — crepitus, asymmetric Moro reflex)

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8G. Chest & Respiratory

Chest shape: ☐ Normal   ☐ Barrel   ☐ Pectus excavatum/carinatum

Work of breathing:
☐ None   ☐ Nasal flaring   ☐ Subcostal recession   ☐ Intercostal recession
☐ Sternal retraction   ☐ Grunting   ☐ Tracheal tug

Breath sounds: ☐ Equal bilaterally   ☐ Reduced: ______ side
               ☐ Crackles   ☐ Wheeze   ☐ Stridor

Percussion (if applicable): ☐ Resonant   ☐ Dull: ______ ☐ Hyperresonant: ______

Breast tissue: ☐ Normal   ☐ Neonatal breast hypertrophy (physiological)
               ☐ Mastitis (erythema, swelling, tenderness)

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8H. Cardiovascular

Precordium: ☐ Normal   ☐ Hyperactive   ☐ Displaced apex
Heart sounds: ☐ S1 S2 normal   ☐ Murmur (describe): ___________________
              Grade: ____/6   Location: ______   Radiation: ______
              ☐ Gallop rhythm

Femoral pulses: ☐ Present & equal bilaterally   ☐ Absent/weak (coarctation)
Brachial pulses: ☐ Normal

Perfusion: ☐ CRT < 3 sec (normal)   ☐ CRT ≥ 3 sec (poor perfusion)
           ☐ Peripheral oedema   ☐ Central oedema

Four-limb BP differential: R arm ______ / L arm ______ / Leg ______ (if coarctation suspected)

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8I. Abdomen

Shape: ☐ Soft/rounded (normal)   ☐ Distended   ☐ Scaphoid (diaphragmatic hernia)
Umbilicus: ☐ Normal (2 arteries + 1 vein)   ☐ Single umbilical artery (renal anomaly)
           ☐ Omphalitis (erythema/discharge)   ☐ Granuloma   ☐ Hernia
           ☐ Omphalocele / Gastroschisis
Bowel sounds: ☐ Present   ☐ Absent   ☐ Hyperactive
Liver: ______ cm below RCM   ☐ Normal (<2 cm)   ☐ Enlarged
Spleen: ☐ Not palpable   ☐ Palpable: ______ cm
Kidneys: ☐ Not palpable   ☐ Palpable (bilateral — PKD / hydronephrosis)
Masses: ☐ None   ☐ Present: describe ______
Anus: ☐ Patent and normally positioned   ☐ Imperforate anus   ☐ Anteriorly displaced

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8J. Genitalia

Male:
☐ Testes descended bilaterally   ☐ Undescended (R/L/bilateral)   ☐ Retractile
☐ Scrotum normal   ☐ Hydrocele   ☐ Hernia
☐ Phallus normal   ☐ Hypospadias (describe position)   ☐ Epispadias
Foreskin: ☐ Normal (non-retractile, physiological)

Female:
☐ Labia majora cover labia minora (term)   ☐ Prominent labia minora (preterm)
☐ Vaginal tag (normal)   ☐ Vaginal discharge (physiological)   ☐ Hydrocolpos
Clitoris: ☐ Normal   ☐ Enlarged (virilization — CAH screen)

Ambiguous genitalia: ☐ Yes — URGENT workup (electrolytes, karyotype, 17-OHP)   ☐ No

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8K. Spine & Back

☐ Intact midline skin   ☐ Sacral dimple (shallow — benign; deep/complex — image)
☐ Spina bifida (myelomeningocele / meningocele)   ☐ Pilonidal sinus
☐ Sacrococcygeal teratoma   ☐ Hairy patch / lipoma (tethered cord)
Spine shape: ☐ Normal   ☐ Scoliosis   ☐ Kyphosis

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8L. Extremities & Musculoskeletal

Limbs: ☐ Symmetric   ☐ Asymmetric movement
Digits: ☐ Normal number   ☐ Polydactyly   ☐ Syndactyly   ☐ Clinodactyly
Palmar creases: ☐ Normal   ☐ Single palmar crease (Down syndrome)
Hands/feet: ☐ Normal   ☐ Clubfoot (talipes equinovarus)   ☐ Rocker-bottom feet (Trisomy 18)

Hips (MANDATORY):
Ortolani test: ☐ Negative   ☐ Positive (clunk on abduction — femoral head relocates)
Barlow test: ☐ Negative   ☐ Positive (clunk on adduction — hip subluxes)
Risk factors for DDH: ☐ Female ☐ Breech ☐ Family history
(If positive or equivocal → refer orthopaedics / USS hips at 6 weeks)

Clavicles: ☐ Intact   ☐ Crepitus / fracture (R/L)

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8M. Neurological Examination

Alertness: ☐ Alert   ☐ Drowsy   ☐ Lethargic   ☐ Comatose / unresponsive
Cry: ☐ Normal   ☐ High-pitched   ☐ Weak/absent   ☐ Cat-like (Cri-du-chat)

Tone:
☐ Normal (strong flexion, symmetric)
☐ Hypotonic — frog-leg position, limbs extended, poor head control
☐ Hypertonic — spasticity / opisthotonos
☐ Asymmetric (lateralizing sign)

Primitive Reflexes (present at term; asymmetry is abnormal):

| Reflex | Present | Absent | Asymmetric |
|---|---|---|---|
| Moro (startle) | ☐ | ☐ | ☐ |
| Rooting | ☐ | ☐ | ☐ |
| Sucking | ☐ | ☐ | ☐ |
| Palmar grasp | ☐ | ☐ | ☐ |
| Plantar grasp | ☐ | ☐ | ☐ |
| Stepping | ☐ | ☐ | ☐ |
| Tonic neck (asymmetric) | ☐ | ☐ | ☐ |

Cranial nerves (if indicated): Facial symmetry ☐ | Eye movements ☐ | Suck-swallow ☐
Seizure activity: ☐ None   ☐ Subtle (eye deviation, cycling)   ☐ Tonic   ☐ Clonic   ☐ Myoclonic

Brachial plexus:
☐ Normal   ☐ Erb's palsy (C5–C6: adduction/internal rotation, absent Moro on affected side)
☐ Klumpke's palsy (C7–C8, T1: isolated hand paralysis)

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8N. Skin

Color: (see General Appearance above)
Jaundice distribution: ☐ None   ☐ Face only   ☐ Trunk   ☐ Below umbilicus   ☐ Palms/soles (severe)

Lesions (common benign — reassure parents):
☐ Erythema toxicum neonatorum (erythematous macules/pustules on trunk, resolves spontaneously)
☐ Milia (tiny white facial papules)   ☐ Mongolian spots (blue-gray sacral pigmentation)
☐ Salmon patch / "stork bite"   ☐ Port wine stain (if facial — Sturge-Weber screen)
☐ Lanugo (fine hair — preterm)   ☐ Vernix caseosa

Concerning lesions:
☐ Vesiculopustular rash (HSV?)   ☐ Petechiae / purpura (sepsis, TORCH)
☐ Bullous lesions   ☐ Congenital melanocytic nevus (large)

Umbilical stump: ☐ Dry/drying   ☐ Moist   ☐ Infected (omphalitis)

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SECTION 9 — APGAR SCORE DOCUMENTATION

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SECTION 10 — GESTATIONAL AGE ASSESSMENT (if uncertain)

Ballard/New Ballard Score: _______ weeks (if performed)
Physical maturity criteria used: ☐ Skin ☐ Lanugo ☐ Plantar surface ☐ Breast ☐ Eye/ear ☐ Genitalia
Neuromuscular criteria used: ☐ Posture ☐ Square window ☐ Arm recoil ☐ Popliteal angle ☐ Scarf sign ☐ Heel to ear

Classification:
☐ Full-term (37–42 weeks)   ☐ Late preterm (34–36⁺⁶ weeks)   ☐ Preterm (<34 weeks)   ☐ Post-term (>42 weeks)

Weight-GA classification:
☐ AGA (10th–90th percentile)   ☐ SGA (<10th percentile)   ☐ LGA (>90th percentile)

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SECTION 11 — WORKING DIAGNOSIS / PROBLEM LIST

1. ___________________________________________________________________
2. ___________________________________________________________________
3. ___________________________________________________________________
4. ___________________________________________________________________

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SECTION 12 — INVESTIGATIONS ORDERED

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SECTION 13 — INITIAL MANAGEMENT PLAN

Feeding:
☐ Breastfeeding — support and encourage
☐ Formula — type: ______  Volume: ______ mL/kg/day  Frequency: ______
☐ IV fluids — type: ______  Rate: ______ mL/kg/day
☐ NGT / OGT — indications: ______

Thermoregulation:
☐ Skin-to-skin / kangaroo care
☐ Incubator (target: 36.5–37.5°C)
☐ Radiant warmer

Monitoring:
☐ Continuous cardiorespiratory monitoring
☐ SpO₂ monitoring   ☐ Hourly glucose monitoring   ☐ 4-hrly vitals

Medications:
☐ Vitamin K given   ☐ Vitamin K to be given — dose: ______
☐ Eye prophylaxis   ☐ HBV vaccine
☐ Other: _____________

Prophylaxis / Infection prevention:
☐ Sepsis screen and empirical antibiotics: ______  (if indicated)
☐ Antifungal prophylaxis (VLBW): ______
☐ Phototherapy (if jaundice): threshold reached ☐ Yes ☐ No

Parental counselling: ☐ Done   ☐ Pending
Consent: ☐ Obtained

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SECTION 14 — SIGNATURE

Examining Clinician: _______________________
Designation: ______________________________
Date / Time: ______________________________
Supervisor review: ________________________  Date: ______________

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Quick Reference — Normal Neonatal Vital Signs

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Sources

• Textbook of Family Medicine, 9th ed. — Sondheimer & Associates, Chapter 21 (Newborn History & Physical Examination, pp. 529–531)
• Tintinalli's Emergency Medicine: A Comprehensive Study, 9th ed. — Chapter 108 (Neonatal Resuscitation, p. 716)
• The Harriet Lane Handbook, 23rd ed. (Johns Hopkins Hospital) — Normal Vital Signs & Drug Dosing
• Fitzpatrick's Dermatology, 9th ed. — Neonatal Skin Diseases (p. 1757)
• Creasy & Resnik's Maternal-Fetal Medicine — Neonatal Assessment