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Nose: Nasal mucosa pink, normal turbinate. No nasal septal deviation, no frontal maxillary sinustenderness.Neck: Full ROM, no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is non- erythematous and without exudate.CardiovascularNormal palpation of heart: PMI nondisplaced; auscultation of heart: regular rate & rhythm. No murmurs heard, Peripheral pulses are strong. No edema noted, brisk capillary refill in all extremitiesRespiratoryNormal respiratory effort, no retractions, no tachypnea, auscultation of lungs are clear & equal breath sounds without rales, rhonchi or wheezing. Symmetric chest walls. Respirations regular and easy, lungs are clear to auscultation bilaterally.GastrointestinalAbdomen: soft, nontender/nondistended, and no mass, no rigidity/rebound or guarding. Normal liver & spleen: no hepatosplenomegaly. Abdomen flat, bowel sounds active in all 4 quadrants. Abdomen soft, non-tender. Abdomen: soft, nontender/nondistended, with increased hyperactive bowel sounds and no mass, no rigidity/rebound or guarding. Normal liver & spleen: no hepatosplenomegaly. BreastBreast are non-tender, symmetrical in nature and no lumps noted.
Pediatric SOAP NoteGenitourinaryBladder is non-distended; no CVA tenderness. External genitalia reveal no labial, vaginal clitoral adhesions noted.
MusculoskeletalFull ROM x 4 extremities, spontaneous movement with no weakness. No focal deficits or trauma Neurological Speech clear. Good tone. Posture erect while in mothers lap. Upper body balance stable. Normal gait around the exam room.PsychiatricAlert and oriented. Dressed in clean jeans and shirt. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.In-house lab testing: NonePediatric/Adolescent Assessment Tools (Ages & Stages etc.) with results and rationale ASQ-3 for 36-month-old administered. Results: Pass in all domains. Child meets all developmental milestones per ASQ-3 assessment tool.Pain Scale: 0 out of 5, no pain.Findings Summary:Home: Lives at home with mother, boyfriend, and two other siblings.Education: Mother has BS in education, child attends daycare while mother works.Eating: Normally eats a balanced diet with fruits and vegetables, good appetite. Activities: Normally very active and energetic, enjoys playing with age-appropriate toys.