CARDIO

No cyanosis, clubbing
No JVD, carotid bruit
No scars, erythema, rash, visible precordial heave
No costochondral, epigastrium tenderness; PMI not displaced
S1S2+; RRR; no m,r,g
Lungs CTA bl
Radial, carotid, post tibialis, dorsalis pedis 2+ sym bl
No pedal edema

RESPIRATORY
No cyanosis, clubbing
No erythema, rash, scars in chest and back
Chest wall expansion sym bl
No spinal/paraspinal tenderness
TVF WNL bl in chest and back
Lungs CTA&P bl in chest and back
No rhonchi, wheezes, rales
S1S2+; RRR; no m,r,g

ABDOMEN
No scars, erythema, rash in abdomen
+BS 4Q; no bruit
Tympanic 4Q; liver nl sz to percussion
Abdomen soft, NT, ND 4Q
No HSM
Neg Murphy, Rebound, CVAT, Obturator

NEURO
A&0X3, good short term memory, concentration, obeys commands, judgment, language spared
CN II-XII intact
Motor strength 5/5 UE LE bl sym
Sensation to light touch UE LE bl sym
DTR2+ sym bl UE LE
Cerebellar-RAM intact, finger to nose, gait normal; Romberg neg
Plantar reflex +
THYROID
No scars, erythema, rash in neck
No thyroid enlargement, bruit, LAD
No skin/hair changes, no tremor, no pretibial edema
S1S2+; RRR; no m,r,g
Radial pulse 2+ sym bl
DTR2+ sym bl

MUSCULOSKELETAL
No obvious deformities, signs of trauma, nodules, erythema, swelling in joints
No tenderness to palpation in joints
ROM decrease in lt elbow
Motor strength 5/5 EU bl sym
Sensation to light touch intact in EU
DTR +2 sym bl UE
Radial pulses 2+ sym bl

PEDIATRIC
 Prenatal hx: routine prenatal checkups, no health complications, meds, cig, ETHO, rec drugs in
pregnancy.
 Birth hx: full term vaginal delivery w/o complications
 Neonatal hx: 8 lbs, no medical problems
 Feeding hx: breast fed, solid foods 6 m, healthy diet, + vit
 Development hx: approp to growth chart, normal milestones
 Routine care hx: last check up 2 wk ago, Immunizations: UTD
 No stress at home/school
 Attends day care
 Doing well at school

HEENT
Head- NC/AT
Eyes- no conjuntival pallor
Ears- canals w/o abnormalities, TM clear
Nose- nasal turbinates not congested
Throat- no tonsillar enlargement, erythema, exudates, vesicles, mucosal pallor
Neck- no LAD