with heightweighthead circumference plotted noting percentiles attach these

With heightweighthead circumference plotted noting

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with height/weight/head circumference plotted & noting percentiles; attach these forms at the end of your SOAP note; include pertinent positives & negatives ) Weight: 35.6lbs 16.1kgs Temp: 100.0 BP: Not measured Height: 42in Pulse 110 Respirations: 22 General Appearance & parent child interaction: ill appearing-appearing tearful, well-nourished, and well-developed. Level of Distress: NAD. Ambulation: ambulating normally. Positive parent-child interaction noted. Skin: C olor pink without evidence of cyanosis, jaundice, or pallor; pigmentation even; no nevi; skin warm, smooth, and dry with elastic turgor; no evidence of edema; no bruising, rashes, or lesions noted Hair: hair well distributed; brown, fine, silky, straight; hair clean and shiny 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; symmetrical, no masses or lesions, hair well-distributed; brown, fine, silky, straight; hair clean and shiny; no nits or scalp lesions seen Eyes: No redness noted. PERRLA. EOMs intact. No conjunctival or scleral injection. eyeballs are in the same plane as eyebrow and maxilla. Lids symmetrical. Ears: External appearance normal-no lesions, redness, or swelling , pinnae normal shape. Otoscopic exam: B ear canal with no erythema, edema, or extudate. Bilateral tympanic membranes clear and mobile no redness, fluid, or bulging noted. Hearing is intact. positive light reflex; landmarks easily visualized. Nose: nose smooth, symmetrical alignment; no deviation or lesions; septum midline without deviation; nares patent bilaterally; turbinates pink, nonedematous; no polyps, lesions, or drainage seen Throat/Mouth: lips pink; no lesions. Buccal mucosa pink without lesions; all deciduous teeth intact; teeth without plaque or visible caries; no malocclusion; gingival tissue pink without bleeding; tongue midline, pink, free of lesions, protrudes strongly at midline (CN XII); soft palate rises symmetrically; B tonsils erythematous. Pharynx erythematous exudate noted; uvula midline;; gag reflex (CN IX and CN X) intact; CN VII and CN IX intact for taste Neck: Head: normocephalic; symmetrical, no masses or lesions, hair well-distributed; head circumference 50th percentile Neck: supple with full range of motion; no swelling, masses; trachea midline; thyroid gland firm without nodules or masses Lymphatics: no lymphadenopathy in head or neck Cardiovascular: S1, S2. Regular rate and rhythm, no murmurs, gallops, or rubs. Carotid Arteries: no bruits present. Pulses upper and lower extremities: 2+ bilaterally. Extremities: no cyanosis, clubbing, < 2 second capillary refill noted. PMI nondisplaced Respiratory: Even and unlabored. Clear to auscultation bilaterally with no wheezes, rales, or rhonchi. No nasal flaring. No intercostal retractions.
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