General Appearance & parent ‐ child interaction: Well-nourished, developmentally appropriate, alert, healthy and active appearing infant. Infant calms with mother. Skin: Normal turgor and without lesions. Nails: nails present on all 10 digits, nail beds pink, not brittle; no evidence of clubbing or other deformities; capillary refill < 2 seconds Head: Normocephalic with age appropriate fontanelles. Eyes: Red reflex present bilaterally. Light reflex symmetric. EOMI, with no strabismus Ears: Ear canals are patent bilaterally; pearly gray TMs, non-bulging in appearance bilaterally Nose: 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 hydration Neck: Soft, supple, without palpable lymphadenopathy; No protrusions or areas of tenderness upon palpation; no nuchal rigidity noted Cardiovascular: 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 skin Genitourinary: Normal male external genitalia. Circumcision healing well. Testes descended bilaterally. No hernia present. Musculoskeletal: No clubbing, cyanosis, or edema. Spine: Straight with no lesions. Joints: Hips with full range-of-motion No hip clicks or clunks. Revised 5/9/18; 8/9/18; 10/29/18
Pediatric SOAP Note Neurological: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age. Behavioral/Psychiatric: Alert and in no distress. Appropriate for age. Pediatric/Adolescent Assessment Tools: 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 on schedule. 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). Present Developmental: The child’s development appears to be appropriate for his age. The child is on schedule with the projected stage from Erikson’s stages of development which is Initiative vs Guilt (Knight, 2017).
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