Vitals Temperature is 103.2, BP is 120/80, HR is
150, RR is 30, weight is 6kg, height is 60cm, head circumference is 33-38cm.
General Patient is a well-nourished year old male
in no acute distress. Normal nutritional status, activity, consciousness.
HEENT Head is normocephalic, atraumatic. Anterior
fontanelle is soft, open, and flat. Posterior fontanelle is closed. No plagiocephaly.
Ears are symmetrical, tympanic membranes are grey with intact light reflex. No acrochordons.
Pupils are equal round and reactive to light and accommodation, extraocular movements intact.
Corneal and red reflexes intact. Sclera are anicteric. Conjunctivae are clear. No proptosis
or strabismus. External nares are patent and non-erythematous.
Mouth has normal palate and dentition. No thrush, vesicles, or buccal lesions. No oropharyngeal
erythema or exudate. Neck
Neck is supple. Normal ROM. No masses, nodules, tenderness, lymphadenopathy or thyromegaly.
Trachea midline. No carotid bruits. No nuchal rigidity.
Cardiovascular Regular rate and rhythm, with normal S1 and
S2. No murmurs, rubs, or gallops. No thrills, no heaves, no displaced point of maximal impulse.
Respiratory Lungs clear to auscultation bilaterally. No
wheezes/rales/rhonchi/stridor or crackles. Chest wall expands symmetrically. Good air
movement. Normal tactile fremitus, no egophony. Gastrointestinal
Abdomen soft, flat, non-tender, not scaphoid. Normoactive bowel sounds. No hepatomegaly
or splenomegaly. No scars or masses. No rebound or guarding. No umbilical cord.
Genitourinary External genitalia circumcised, no hernias,
hydroceles, hypospadias or cryptorchidism. Anus is patent. Tanner stage 1.
Skin Skin is warm and dry. No jaundice, hemangiomata,
birthmarks, scars, injuries. No rashes, lesions, ulcerations, subcutaneous nodules, bruising
or petechiae. Extremities
Femoral, brachial, and DP/PT pulses intact 2+ bilaterally. Normal turgor and temperature.
Brisk capillary refill. No clubbing or acrocyanosis. Musculoskeletal
No sacral dimple. Clavicles are supple. Negative Barlow, Ortolani, Galeazzi signs. No clicks
or subluxation. Normal muscle tone and bulk. Full ROM throughout and 5/5 strength in all
extremities. No joint swelling or tenderness. Neurologic
Cranial nerves 2 through 12 grossly intact. Moro, rooting and grasp reflexes intact. Negative
Chvostek’s sign. Face is symmetrical. No dysarthria or dysphasia. Normal sensation
to light touch and proprioception. Deep tendon reflexes intact 2+ bilaterally. No clonus.
Babinskis downgoing bilaterally. Normal finger-to-nose and heel-to-shin tests. No in-toeing, bow
legs, or limp. Romberg not assessed.