Alyssa Matulich

Physical Exam: 4 days old

VS: Temp 97.9 RR 27 HR 93 Weight 6lbs 10oz Height: 20 in

Pt awake and alert, present with mother

Vaccines: pt had Hep B at birth no other vaccines until 2 months old

Head: Normocephalic, oval without deformities. Hair is clean, brown, evenly distributed
throughout without infestation. Fontanels soft and flat. Skin is pink and dry without lumps,
lesions, or scales. Temporal arteries without bruits.

Neck/Throat: Trachea midline without tugging. Cervical range of motion intact. Carotid arteries
symmetrical, pulse waveform with distinct beginning and end without bruit. Thyroid
symmetrical, no enlargement, no tenderness, no lumps. No jugular venous distension. No
lymphadenopathy.

Eyes: symmetrical, irises brown, pupils equal and reactive to light bilaterally. Conjunctiva pink,
Sclera white, no drainage or discharge bilaterally. No strabismus. No nystagmus. Normal eye
movement bilaterally. Red reflex present.

Ears: rounded, even with outer eye canthus, helix firm bilaterally. Ear lobes symmetrical. No
deformities, no lesions, no drainage externally. Internal auditory canal without drainage,
redness, edema, pain, and tenderness bilaterally. Tympanic membrane visible, grey, translucent
without inflammation. Landmarks visible, cone of light at 5 o clock in right ear and 8 o clock in
left ear.

Nose: appropriate size for face, color confluent with entire face. Nasal mucosa pink and moist
no turbinates visible. No discharge, no sinus swelling or tenderness. Septum midline.

Mouth: Lips pink, moist, symmetrical. Buccal mucosa pink and moist without lesions. No teeth.
Gums pink and moist without bleeding and tenderness. Tongue soft, pink, midline with full
range of motion intact. Tonsils +1 without swelling, exudate, or drainage. Uvula midline. Hard
and soft palates intact. Palatine arch rounded

Skin: skin uniformly warm and dry, resilient, turgor < 2, no edema. Pink in color. Hair has
female distribution pattern. Nails are nontender, medium length, clean, without deformities.
Nail bed pink, nail base 160 degrees, no redness, exudate, or swelling around folds.

Chest/Lungs: Skin pink and warm. No pallor. No cyanosis. AP/Lateral Ratio 1:2, no barrel chest,
no pectus excavatum, no pectus carinatum. Chest movement symmetrical, Respirations equal
and regular, non-labored, no accessory muscle use. Chest expansion symmetrical. Breath
sounds clear in all fields. No adventitious breath sounds.

Heart/blood vessels: PMI nondisplaced at 5th intercostal space at the midclavicular line.
Regular heart rate and rhythm. S1 and S2 equal. No splitting, no murmurs, no bruits, no lifts, no
heaves, no thrills. Carotid pulses equal bilaterally with crescendo and decrescendo, rate regular.
No JVD. Pulses 2+ bilaterally on upper and lower extremities. No edema.

Abdomen: Skin pale, pink, no venous pattern visible. Umbilical clean and dry. Abdomen
rounded and symmetric. No distension. Umbilicus midline, no herniations, no masses. Bowel
sounds in all four quadrants. No hepatomegaly, no splenomegaly. Tympany predominant in all
four quadrants. No tenderness on palpation.

MS: Curvature of cervical, thoracic, and lumbar spine is appropriate. No kyphosis, no lordosis.
Joints appropriate size and contour with no swelling or crepitus. All joints have full range of
motion. No edema, spasms, masses, atrophy, hypertrophy in any muscle groups bilaterally.

Neuro: Awake and alert. Root and suck reflexes intact. Moro and grasp reflexes intact. Babinski
reflex present. No posturing.

Plan: Pt weight gain is appropriate and feeding well according to mother. Mother is adjusting
well, will reassess postpartum depression again at next visit. Mother has follow up with OBGYN
already scheduled. Next visit for pt will be at one month old. No vaccines today. Vaccines due at
two-month visit will be Hep B #2, IPV #1, Dtap #1, P13 #1, Hib #1, Rota #1

ICD 10: well child exam Z00.129

CPT: 99383 well visit