HISTORY TAKING AND
PHYSICAL ASSESSMENT
IN THE NEWBORN
DR. O.A.T. FATUNLA
ABUAD, SEPTEMBER 2022
LEARNING OBJECTIVES
• At the end of the lecture, each student should:
1. Know the peculiarities of history taking in
neonatology
2. Know how to examine the newborn and make
inferences from the findings
HISTORY TAKING IN NEWBORN
• Importance of history taking
• To identify clinical problems
• Suggests what clinical signs to look for during
examination
HISTORY TAKING IN NEWBORN
• Biodata
• Presenting Complaints
• History of Presenting Complaints
• Pregnancy and Delivery History
• Nutritional History
• Immunization History
• Developmental History
• Family and Social History
HISTORY TAKING – BIODATA
• Name
• Chronological Age: Exact age In minutes, hours, days or weeks
• Gestational age: If preterm, exact gestational age in weeks
• Sex
• Religion: Parents’ religion
• Address
• Ethnicity
• Informant:
• State if the information is reliable;
• State why you think information is reliable or not reliable
HISTORY TAKING – PRESENTING
COMPLAINTS
• Presenting Complaints:
• Why has this neonate come to you?
• Common examples include:
• Inability to/poor cry at birth
• Refusal to feed
• Yellowness of the eyes
• Convulsion
• Vomiting
• Abdominal distension etc
• Duration of illness: Reference often made to time of delivery
HISTORY TAKING
– HISTORY OF PRESENTING
COMPLAINTS
• History of Presenting Complaints:
• Each complaint should be reviewed in chronological order
• Report what the informant tells you
• Avoid technical terms
HISTORY TAKING
– HISTORY OF PRESENTING
COMPLAINTS
• History of Presenting Complaints:
• This should include:
• Complaints: mention the complaint, state the duration of the complaint,
describe the character of the complaint
• Course of the complaint: describe the pattern of the complaint, describe how
the complaints had evolved
• Cause: explore the possible causes of the complaints, highlight the symptoms
that are peculiar to the diseases that can explain the symptoms patient has
• Complications: ask direct questions to anticipate possible complications
associated with the illness
• Care given so far: this should include admissions, drugs, surgeries, blood
transfusions; describe the present state of the baby in relation to the presenting
complaints
HISTORY TAKING
– MEDICAL AND SURGICAL HISTORY
• Medical History:
• Previous admissions/interventions
• Previous illnesses
• Previous blood transfusions
• Surgical History:
• Previous surgeries including circumcision
HISTORY TAKING – PREGNANCY
HISTORY
• Pregnancy History:
• Was the pregnancy desired?
• Any attempt at terminating the pregnancy?
• Is this a singleton or multiple gestation?
• Any maternal illness in pregnancy? – malaria, urinary tract infection,
maternal rash, hypertension, diabetes mellitus, epilepsy, sickle cell
disease, etc
• Any adverse events in pregnancy? – bleeding par vaginam, abnormal
ultrasonography
• Mother’s age
• Mother’s drug history including social drugs
• Mother’s blood parameters – Blood group, genotype, retroviral
screening, hepatitis, etc
HISTORY TAKING – DELIVERY
HISTORY
• Delivery History:
• Gestational age at delivery
• Birth weight and placental weight(if known)
• Place of delivery
• Method of delivery: spontaneous vaginal delivery, caesarean
section
• Cry/Spontaneous breathing at birth
• APGAR score (if available)
• Interventions done during resuscitation
• Circumstances surrounding delivery: e.g. prolonged rupture of
membrane, duration of labour
HISTORY TAKING – NUTRITIONAL
HISTORY
• Nutritional History:
• Has baby been fed?
• What was baby fed with?
• When did feeding commence?
• Frequency of feeding
• If on artificial feeds
• Why?
• How were feeds prepared? – Appropriate or not
• Method of feeding: cup and spoon or bottle feeding, number of
bottles and care of bottles
• Last time baby was fed
• If not fed, why?
• Has baby moved bowel? Number of times
HISTORY TAKING
– IMMUNIZATION AND DEVELOPMENTAL HISTORY
• Immunization History:
• Has the neonate been immunized?
• List the ones baby has had
• Is the immunization card available?
• Developmental History:
• Can focus on objects 8 to 14 inches away at week 2
• Coos and ‘ahh’ sound by week 4
HISTORY TAKING – FAMILY HISTORY
• Family History
• Parents’ ages
• Number of siblings
• Are they alive? If not, cause of and age at death
• Birth weights and gestational ages of each sibling
• Problems with siblings e.g. neonatal jaundice, congenital
anormalies
• Any family history of inherited diseases?
• Maternal gynaecology and obstetric history: including infertility
• Major medical events in siblings including the outcomes
HISTORY TAKING – SOCIAL HISTORY
• Social History
• Parents’ level of education, occupation and income
• Parents’ marital status
• Any previous partners for either parent?
• Living circumstances including housing, water supply
RECESS – 5minutes
• Questions
• Clarifications
PHYSICAL ASSESSMENT IN NEWBORN
• Requirements:
• Baby’s mother (where feasible)
• Warm environment
• Good light source: preferably natural
• Facilities for thorough hand washing
• Baby should be completely undressed
PHYSICAL ASSESSMENT IN NEWBORN
• The following measurements are necessary:
• Baby’s weight
• Baby’s head (occipitofrontal) circumference
• Baby’s length
• Assessment of the gestational age: necessary for
interpreting the measurements obtained
• Baby’s temperature
INFANTOMETER
PHYSICAL ASSESSMENT IN NEWBORN
• General inspection
• Level of consciousness
• Baby’s activity
• Skin colour
• Paleness
• Jaundice
• Cyanosis
• Others: Meconium staining, Bruises, Petechiae etc
• Level of hydration
• Presence or absence of oedema
PHYSICAL ASSESSMENT IN NEWBORN
• Head:
• Shape of head
• Fontanelles: Anterior, Posterior, Any third fontanel?
• Normal sided, Closed/Fused, Wide
• Full, Bulging or Sunken
• Swelling:
• Caput succaedaneum, Cephalhematoma, Sub-galeal hemorrhage
• Eyes:
• Number
• Size
• Integrity of the lids, cornea, conjunctiva, iris
PHYSICAL ASSESSMENT IN NEWBORN
• Nose:
• Shape of nose
• Nostrils: Patent, Choanal atresia,
• Discharge/Secretions: Mucus, Pus, Meconium, Blood
• Mouth:
• Lips: Cleft lip, Flat philtrum of the lip (fetal alcohol syndrome)
• Palate: Cleft palate, high arched, Epstein’s pearls
• Tongue: Cyanosed, pale, large, bifid, ankyloglossia, thrush, milk
curd
• Teeth: Natal teeth
• Jaw: Normal or Small
PHYSICAL ASSESSMENT IN NEWBORN
• Ears:
• Number
• Appearance: Skin tag, sinus, malformed
• Location: Normal or low-set
• Discharge: Pus, Blood
• Neck:
• Shape: Webbed, Torticollis
• Masses
• Clavicle: Any fracture?
• Breasts:
• Number of nipples, wide spaced, any discharge?
• Swelling
PHYSICAL ASSESSMENT IN NEWBORN
• Heart:
• Pulses
• Rate: normal is 120 – 160 beats per min
• Rhythm
• Synchronicity
• Character
• Blood pressure:
• Normal systolic: 50 – 70 mmHg
• Diastolic: two-thirds of systolic
• Apex beat: dextrocardia?
• Heart sounds: normal, murmurs
PHYSICAL ASSESSMENT IN NEWBORN
• Respiratory System:
• Inspection:
• Respiratory pattern: normal, gasping, kussmaul’s, cheyne-
stokes, apnoiec
• Periodic breathing: cessation of breathing, usually less than 20
seconds without palor, cyanosis, bradycardia or hypotonia.
Normal and common in neonates
• Apnoea: cessation of breathing for 20 seconds or more associated
with palor, cyanosis, bradycardia and/or hypotonia
• Respiratory rate: normal 40 – 60 breaths per minute
• Chest shape and movement
PHYSICAL ASSESSMENT IN NEWBORN
• Respiratory System:
• Palpation:
• Trachea position
• Chest expansion
• Percussion: Resonant, hyperresonant, dull, stony dull
• Auscultation:
• Breath sounds
• Added sounds: Transmitted, Crepitations
PHYSICAL ASSESSMENT IN NEWBORN
• Abdomen:
• Inspection:
• Shape
• Skin
• Umbilicus: normal contains two arteries and one vein, hernia,
bleeding, exomphalus, gastrochisis
• Palpation:
• Liver
• Spleen
• Kidneys
• Bladder
• Other masses
PHYSICAL ASSESSMENT IN NEWBORN
• Abdomen:
• Percussion: Tympanitic
• Auscultation:
• Bowel sounds
• Anus:
• Patent
• Passage of meconium
PHYSICAL ASSESSMENT IN NEWBORN
• Genitals:
• Is the genitalia ambiguous?
• Males:
• Penis: Location of urethral orifice, Penile length
• Testes: Palpable or not, location of testes
• Scrotum: Rugae, any hernia
• Females:
• Vulva: Describe the labia
• Clitoris: comment on size and integrity
• Urine: Stream
PHYSICAL ASSESSMENT IN NEWBORN
• Musculoskeletal:
• Spine: Appearance, scoliosis, any defect, dimples etc
• Arms: Fractures, Nerve palsies
• Hands: Digits, palmar creases, overgrown nails at birth
• Legs and feet: Bowing, clubbed feet, digits, rocker bottom feet
• Hips: Dislocated
PHYSICAL ASSESSMENT IN NEWBORN
• Neurological status:
• Behaviour: Alert, drowsy, unconscious
• Position: Commonly flexed. Extended in preterm or ill infants
• Activity: Normal, listless, jittery or convulsing
• Tone
• Primitive reflexes: Moro reflex, sucking reflex, rooting reflex,
grasp
FURTHER READING
• Bettercare Learning Programmes/Newborn Care/Skills:
Clinical history and examination.
https://bettercare.co.za/learn/newborn-care/text/03a.html#
taking-a-perinatal-history
• Chapter 6: Newborn Physical Examination; Section II. Basic
Management; In Neonatology: Management, Procedures,
On-Call Problems, Diseases and Drugs. 7th Edition; Editors,
Tricia Lacy Gomella with M. Douglas Cunningham and Fabien
G. Eyal; pp 43 – 65
