No nasal drainage noted Neck Supple Full ROM No cervical or occipital

No nasal drainage noted neck supple full rom no

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No nasal drainage noted. Neck: Supple. Full ROM. No cervical or occipital lymphadenopathy noted. Non-enlarged thyroid. No nodules present. Mouth: Oral mucosa pink and moist with drool present. Four front teeth present on bottom and top of gums. Back molar gums erythematous. No decay or signs of gum disease noted. Cardiovascular Regular rhythm and rate for age. S1 and S2 noted. No rubs, murmurs, snaps or gallops noted. No thrills, heaves, or lifts with palpation. No cyanosis, clubbing, or edema noted. Radial and femoral pulses 2+ bilaterally. Respiratory Chest wall rise is symmetric. Respirations even and unlabored. Lungs clear to auscultation bilaterally. Gastrointestinal Abdomen is soft, round, and non-distended. Bowel sounds present in all 4 quadrants. Abdomen tympanic with percussion. No abdominal tenderness with palpation. No organomegaly. Breast Breasts are symmetrical without nipple inversion or discharge. Genitourinary Normal male external genitalia. Circumcised penis. Descended testes bilaterally. No inguinal hernias seen. Musculoskeletal Full ROM noted while watching patient walk throughout exam room. Muscle tone and strength are normal. Neurological Reflexes are 2+ bilaterally. Developmentally appropriate for age. No focal deficits noted. Psychiatric Alert and oriented to name. Well-groomed and clean in appearance. Very social with staff. In-house Lab Tests–document tests (results or pending) None Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale For adolescents(HEADSSS Assessment) The most commonly used developmental screening test in pediatric care is the Denver (II) Developmental Screening tool (Çelikkiran, Bozkurt, & Coşkun, 2015). This tool measures the child’s development by using 125 items that are divided into gross motor, fine motor-adaptive, personal-social, and language skills (Celikkiran et al., 2015). Each item is scored as a pass fail, refusal, or no opportunity (Celikkiran et al., 2015). After grading J.P. on this screening tool, he appears to have no developmental deficits, as he either performed all items or his mother reported that he performed the items at home appropriate to his age. Furthermore, the Bayley Scales of Infant Developmental III or Bayley-III is also one of the most widespread developmental screening tools used in infants from 0 months to 42 months of age (Yue et al., 2019). The primary purpose of this screening tool is to identify children with developmental delays and provide information for intervention planning (Yue et al., 2019). The tool does not take up a lot of the providers time (15-20 minutes) and assesses 4 developmental areas including: (1) basic neurologic functions (posture and muscle tone), (2) expressive functions (oral/verbal functions and gross motor skills), (3) cognitive functions (problem solving and object permanence), and (4) receptive functions (auditory, verbal, and visual) (Yue et al., 2019). J.P.’s score was a 19, which indicates that he is at low risk for developmental delay (Yue et al., 2019).
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  • Summer '17
  • J.P., birth mother

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