child interaction: Well nourished, 13 year-old male in no acute distress. Appears her stated age.Skin: Normal turgor Erythema noted to L great toe extending to the doral aspect of the L foot pedal pulse intact.Nails:nails present on all 10 digits, nail beds pink, not brittle; no evidence of clubbing; capillary refill < 2 secondsHead: Normocephalic hair evenly distributed. Blonde, clean. Eyes: pupils equal and reactive to light and accommodation, extraocular movementsintact.Ears:Ear canals are patent bilaterally; pearly gray TMs, non-bulging in appearance bilaterallyNose:nose smooth, symmetrical alignment; no deviation or lesions; septum midline without deviation; nares patent bilaterally; Throat/Mouth:Oral mucosa is pink, moist, and intact with gingival tissue pink. Hard and soft palate are without obvious malformation or trauma; Posterior pharynx is clear in appearance; appropriate amount of saliva noted to ensure adequate hydrationNeck: Soft, supple, without palpable lymphadenopathy; No protrusions or areas of tenderness upon palpation; no nuchal rigidity notedCardiovascular:Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs.Peripheral Vessels: appropriate pulses and perfusion.Respiratory: Unlabored respirations; symmetric chest expansion; clear breath sounds.Gastrointestinal: Soft, without organomegaly. Bowel sounds normal. Nontender without rebound. No masses palpable. No distention.Breast:Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skinGenitourinary: Deferred Musculoskeletal: Good muscle bulk and tone. Strength 5/5 in all four extremities. Muscle strength equal andRevised 5/9/18; 8/9/18; 10/29/18
Pediatric SOAP Notesymmetrical. Fine motor and gross motor intact. Denies Numbness or tingling in all four extremities. Back: No CVA tenderness. Spine: Straight with no lesions.Neurological:A&O x 4 reflexes 2+ and symmetrical in upper and lower extremities bilaterally. Behavioral/Psychiatric:Alert and in no distress. Appropriate for age.Pediatric/Adolescent Assessment Tools:There was no assessment tool used during this visit as this was a sick visit. However, the appropriate tool to use would be the Ages & Stages Questionnaires- According to the ages and stages questionnaire the child’s development appears to be onschedule. Rationale: This tool is essential for children from birth to 8 years. It is important in determining the social difficulties that the patient might be experiencing as well as emotional factors (The American Association of Pediatrics, 2017).
- Summer '17
- Toe, Unlabored respirations