Respiratory Mother report breathing rapidly Denies wheezing, chest tightness, difficulty breathing and shortness of breath Eyes Denies itching, eye pain, blurred vision, eye redness, swelling and discharge Gastrointestinal Mother reports abdominal pain and vomiting x 1 Denies constipation, gastric reflux, rectal pain, bowel changes, flatulence, bloody/dark stools. Ears Denies pulling at ears, ear pain and ear discharge Genitourinary/Gynecological Mother reports decreased wet diapers and foul-smelling urine Denies any urinary frequency, incontinence, genital ulcers or lesions, polyuria, hematuria and painful urination. Nose/Mouth/Throat Mother denies drooling, facial swelling, difficulty swallowing and hoarseness. Musculoskeletal Mother denies soft tissue swelling, joint swelling and myalgia Breast Deferred Neurological Mother reports child is less responsive Mother denies seizures, trouble walking or syncope. Heme/Lymph/Endo Mother reports that child bruises easily Mother denies heat/cold intolerances, anemia and blood diseases Psychiatric Mother reports change in mood and whiny OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart Weight 10kg (22 pounds) BMI 19.7 Temp 97.9 F BP 68/40 Height 71cm (27.953 inches) Pulse 160 Resp 50 General Appearance and parent ‐ child interaction : Pale, listless, small for age child ill appearing and in obvious distress with evidence of bruising to the abdomen and old ligature marks noted on bilateral wrists. Skin General: no cyanosis but mottled; Moisture: diaphoretic; Lesions: no petechiae or rashes. Bruising noted to abdomen and old ligature marks to bilateral wrists HEENT Head is normocephalic and atraumatic, no tenderness or swelling Eyes: round, non-injected, equal size, reactive to light, and no exudates. Ears: pinna well-formed, no pits, right TM erythematous and dull. Nose: no crusts/sores. Throat: no erythema or exudate and not enlarged; poor dentition and dental caries. Neck: supple and no lymphadenopathy. Cardiovascular Heart Sounds: regular rate and tachycardic, grade 3/6 murmur, no rubs, gallops or clicks or rub; pulses +1 throughout, no clubbing noted to extremities, edema, skin mottled throughout Respiratory Auscultation: no wheezing, rales/crackles, rhonchi, or retractions noted; lungs clear to auscultation; equal rise and fall of chest and tachypneic Gastrointestinal Abdomen firm, tender on palpation with rebound tenderness and guarding, distension noted, no noted hepatosplenomegaly, reduceable umbilical hernia Breast Not performed
Genitourinary Not performed Musculoskeletal No clubbing, cyanosis or edema noted. Moves all extremities and no deformities noted. Neurological Normal reflexes and normal tone but weak. CN I-II intact. Speech unable to be assessed.
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