Skin Admits bruise on abdomen. Denies rash, lesions. Respiratory Admits increased respiratory rate. Denies difficulty breathing. Eyes Denies itchy, watery eyes. Gastrointestinal Admits abdominal pain. Denies changes in bowel. Ears Denies hearing loss, pain. G e n i t ou r i n a r y / G y n ec o l o g i c al Admits decrease urine output, decreases frequency of diaper changes. N o s e / M ou t h / T h r o at Admits nasal congestion. Denies sores in mouth or throat. Musculoskeletal Admits weakness, falls. Denies changes in gait. Breast Denies changes in size, shape, or skin. Neurological Denies dizziness, seizures. H e m e / L y m ph / En do Admits frequent bruising. Psychiatric Admits fussiness, decreased activity level.
OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart Weight 22lbs Temp 97.9 BP 68/40 Height 28in Pulse 160 Resp 50 OBJECTIVE (Physical Examination) General Appearance and parent - child interaction Skin Skin appears cool, sweaty, and slightly mottled. Thoracotomy scar from AV septal repair. Diffuse diaper rash. Faint circumferential macular discolorations at wrists consistent with aging ligature marks. HEENT Flat face, up slanting eyes consistent with Down syndrome. No signs of trauma. Ear canals are clean and free of lesions. Gray TM intact. Cardiovascular Heart murmur auscultated. Regular rate and rhythm. No SOB. Respiratory No abnormal breath sounds present. Gastrointestinal Abdomen distended, muscle guarding and rebound. Reducible umbilical hernia. Bowel sounds present. Breast Non-tender, no lumps, masses, deformities, ulcerations, or discharge. Genitourinary Atraumatic, diffuse diaper rash, circumcised, testes descended, non-tender. No inguinal hernia. Musculoskeletal
Normal bulk, no rigidity, no signs of trauma. Full ROM. Neurological Normal bulk, no rigidity, no signs of trauma, no involuntary movements. Normal DTR 2+.Negatvie Babinski bilateral. Psychiatric Fussiness present. In-house Lab Tests – document tests (results or pending) CBC- Elevated WBC’s, decrease H&H, decreased platelets CMP- Elevated Na+, elevated K+, decreased calcium, chloride, and CO2, increased BUN and creatinine, decrease albumin, decrease protein.
You've reached the end of your free preview.
Want to read all 6 pages?
- Summer '17
- NSG6435 Discussion