Professional Documents
Culture Documents
HPl: Complaining of nasal congestion, cough, and low gj'ade temperature for a few days. ROS Resp: Negative for difficulty breathing GI: Negative for abdominal pain, vomiting, and diarrhea ENT: TM's clear bilaterally; nares with clear discharge; o ro phar-vnx moist, no lesions Resp: CTA throughout CV: RRR, no murmur G I: l~ bd 0 men soft, no in as ses j no HSM MS: No clubbing, cyanosis, or edema Skin: Normal temperature, diaper area,. slight papular rash noted Neuro: OTR's 2+ bilaterally; CN II-XII intact grossly; 5/5 muscle s t r anqt h R: Viral Syndrome/DIAPER RRSH
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P: Symptomatic care discussed. Report new or worsening symptoms. F!U t~CC. --+-Refill Nystatin given to mom. Document Electronically Signed by Dawn Diomede, RRNP Finalized Time Stamp: 8!l9!2013
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Medical Concerns:Mom is concerned about the care that child is receiving when at his father's house during limited visitation weekly. Mom states that log books s~ow that child has not been fed adequatelv or things that are age-;pprop~iate.
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DEVELOPMENT SCREEN: DDS II Walks without support - Yes Points - Yes Vocabulary - )4 words Well-developed pincer' gr'a:;p Stoops and recovers-Yes PHYSICAL EXAM: O=Normal X=Abnormal Wt 25 l.ile length 75 '1.ile HC 75 '1.ile Skin - Cleal"' with no rashe s, lesions noted on exam Head - I] Eyes/RR - 0 ENT - 0 Teeth-O Nodes - 0 Chest/Lungs - 0
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