‐ 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. Pupils equally round and reactive to light 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. Normal upper and lower extremities. Spine: Straight with no lesions. Joints: Hips with full range-of-motion; negative Barlow and Ortolani. 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.
- Summer '17
- Pediatrics, Unlabored respirations