Sclera is white no drainage noted Cornea intact Eyelids pink skin colored no

Sclera is white no drainage noted cornea intact

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Sclera is white, no drainage noted. Cornea intact. Eyelids pink, skin colored, no lessons or masses noted. Eyebrows are blonde in color, thick, and evenly distributed. Ears: Bilateral tympanic membranes are pearly grey with a good cone of light. Light reflex present. No perforations of tympanic membranes noted. Nose: There is no nasal drainage present. No pain upon palpation of sinuses. Septum is midline, no deviation noted. Nares are patent. Throat/Mouth: Oral mucosa is pink, intact, moist. No bleeding noted. Routine dental screenings performed every 6 months. Oral hygiene intact. No deformities or malformations noted on hard and soft palate. Deciduous teeth intact. Top upper left molar coming through. Posterior pharynx erythematous, no exudate noted. Tongue is midline. Tonsils are not enlarged and there is no exudate. Neck: Full range of motion noted. No stiffness or difficulties noted. Thyroid moveable, no enlargement noted. Trachea midline. Lymph noted palpable, no tenderness upon palpation. Cardiovascular: Rate and rhythm regular. S1 and S2 noted. Heart murmur auscultated early systolic. Pulses +2 bilaterally. No edema noted. Respiratory: Patient is tachypneic, lung sounds clear bilaterally. No wheezing, crackles or stridor noted. Chest moved symmetrically. Gastrointestinal: Abdomen is distended and tender. Patient is rigid and guarding is present. There is an umbilical hernia, it is soft and easily palpable and reducible. There is a 10 cm oval bruise noted to the left side of the abdomen. Bowel sounds are present in all 4 quadrants. Breast: No masses, lesions, tenderness, or discharged noted. No dimpling or discoloration of skin noted . Genitourinary: No CVA tenderness. Tanner stage I. Musculoskeletal: No deformities. Patient is able to grip thumb with both hands. Can stand and step Revised 5/9/18; 8/9/18; 10/29/18;10/22/19
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Pediatric SOAP Note when held up. Neurological: Occipital fontanel is closed. Patient follows mother with eyes and head but is listless, makes poor eye contact. Behavioral/Psychiatric: Withdrawn. Eye contact is minimal. Showing signs of distress. Pediatric/Adolescent Assessment Tools: Vital sign assessments tool, age appropriate faces. Pain- non-verbal pain symptoms positive- guarding and grimacing. Patient lives at home with mother and two siblings. Does not attend day care, spends the day with his mother’s boyfriend or neighbors. Patients appetite has decreased. Usually an active and social little boy. The patient usually likes to be held and follows and looks at his mom when she is talking to her baby. Now the patient is withdrawn and is listless. Patient is safe at home and rides in a car seat that is rear facing, measures have been taken to remove small objects form the house that the baby could choke on. He developed at a slower pace than most kids his age due to Down Syndrome. He can step with both feet and say a couple words. Present Developmental: Child developmentally delayed Lab and/or Diagnostic Tests: CBC- WBC elevated, Hgb low; CMP-electrolytes off, BUN & Creatinine-elevated; Lactic acid-elevated; Lipase-elevated; PT/INR-elevated; UA-negative; CT abdomen/pelvis- duodenal hematoma, distended; CT Head-Within normal limits; Skeletal survey- multiple rib fractures in different stages of healing.
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  • Summer '17
  • Down syndrome, Sepsis

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