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hour secured gated community and feel safe in their home. The family has two English Bulldogs in the home. ROSGeneral Mother denies any weight loss, fatigue, changes in sleep or eating patterns, fever, chills or sweats.CardiovascularMother denies any previous heart conditions, no blue or cold fingers. SkinMother reports patient to have Mongolian spot onbuttocks, denies any skin lesions or rashes, no itchiness. RespiratoryMother reports patient to have chronic cough with congestion, denies any respiratory infections, breathing difficulties, apneic spells, or snoring. EyesMother reports continuous thick, yellow/green eye discharge, crusting to eye lashes, and swolleneye lids with redness noted this morning. GastrointestinalMother denies any nausea, vomiting, diarrhea, abdominal pain, blood in stools, constipation, bloating or tarry stools. EarsMother reports purulent drainage from left ear since last night and again this morning. Genitourinary/GynecologicalMother reports no change in amount of wet diapers per day, denies any changes in color of urine. Nose/Mouth/ThroatMother denies drooling or issues swallowing, reports clear rhinorrhea. MusculoskeletalMother denies any history of injuries; reports patient crawls and stands appropriately. BreastMother reports no issues. NeurologicalMother denies changes in mental status. Heme/Lymph/EndoMother denies history or anemia, blood transfusions or bleeding disorders. No growth delays.PsychiatricMother denies irritability or fussiness; reports patient is a happy child. OBJECTIVEGrowth Chart Attached Weight 11.2 kgTemp97.9BP96/57Height 32 inchesPulse112Resp24General AppearanceHealthy appearing male infant in no acute distress. Sitting on Mothers lap, playing with soft babybook. Patient is clean and dressed appropriately, appears well nourished and comfortable with mother and father.
SkinSkin is normal for ethnicity, warm, dry, clean and intact. No rashes, bruises or lesions noted. HEENTHead: normocephalic, non-tender without lumps, bumps, round with no depressions; hair is sparse and evenly distributed. Eyes: PERRLA. EOMs intact. Purulent bilateral eye drainage with mild orbital edema and redness to eyelids. Eyelashes with yellow crusted discharge.Ears: Canals patent. Right TM pearly grey/Left TM erythematous with purulent discharge, myringotomy tubes noted bilaterally. Nose: Nasal mucosa pink; clear rhinorrhea bilaterally. No septal deviation. No frontal or maxillary sinus tenderness. Neck: Full ROM; no cervical lymphadenopathy; no occipital nodes. Oral mucosa pink and moist,hard and soft palate intact. Pharynx is non-erythematous and without exudate. Two upper and lower teeth noted.