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Acute Pediatric Exams
Nov 25, 2010
•
Mark Morgan
categories:
Objective/Exam
Pediatrics
Febrile Infant
Fussy Infant
Chicken Pox
Croup
Upper Respiratory Infection
General Appearance: NAD, no lethargy, not toxic.
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Head: normal, fontanele is soft.
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Eyes: normal pupils, lids, and conjunctiva. No exudate.
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Nose: normal, without congestion.
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Ears: right ear clear. left ear clear.
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Throat: normal, without erythema or exudate.
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Cervical adenopathy: absent bilaterally.
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Neck: supple.
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Heart: RR, no murmur/click, S3/S4
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Lungs: clear, no wheezes, retractions, or rhonchi.
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Abdomen: normal, nontender, bowel sounds are present, no hepatosplenomegaly
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Extremities: normal. Capillary refill less than 2 seconds.
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Genitalia: normal.
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Skin: normal turgor, no rashes or lesions present.
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General Appearance: active. Not toxic, not irritable, not inconsolable, not lethargic or listless.
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Head: normal, fontanelle is soft.
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Eyes: normal pupils, lids, and conjunctiva.
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Ears: right ear clear. left ear clear.
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Throat: normal, without erythema or exudate.
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Neck: normal, Kernig and Brudzinski negative.
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Heart: normal heart sounds, no murmur.
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Lungs: clear, without rhonic.
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Abdomen: no tenderness, no mass nor organomegaly, normal bowel sounds.
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Extremities: normal. Capillary refill less than 2 seconds.
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Skin: normal turgor, no rashes or lesions present.
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General Appearance: NAD, Alert, well nourished and well hydrated, non-toxic appearing in no medical distress.
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HEENT: Conjunctiva normal, Auditory canals and TM's normal, nares clear rhinorrhea bilaterally, oral exam without lesions, palate, tonsillar pillars and posterior pharynx non-erythematous. No palpable sinus pain.
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Neck: supple, no adenopathy.
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Lungs: clear to auscultation without wheezes, rales, or rhonchi. Good excursions.
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Heart: RRR with normal S1, S2 without murmur, gallop, or rub.
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Abdomen: soft, flat; no masses, tenderness or organomegaly.
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Skin: No rash present.
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Extremities: normal. Capillary refill less than 2 seconds.
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General Appearance: no acute respiratory distress. Non-toxic appearing. Without barky cough or hoarse voice.
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Ears: bilaterally intact TMs without bulging or erythema.
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Throat: normal, without exudate or tonsillar hypertrophy.
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Lymph nodes: normal, without anterior or posterior cervical adenopathy.
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Heart: RR, no murmur/click, S3/S4.
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Lungs: clear. No nasal flaring. No intercostal retractions. No stridor. No wheezes, rhonchi, or crackles.
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Abdomen: normal bowel sounds, soft, nontender.
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Extremities: Capillary refill is normal, less than 2 seconds.
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Skin: Color is good, without cyanosis.
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The patient is alert, NAD. Non-toxic appearing.
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Eyes: PERRL, conjunctiva normal. lids are normal.
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Ears: canals and tympanic membranes intact and without erythema bilaterally.
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Oropharnynx: no ulcers or vesicles. no erythema or exudate at posterior pharynx.
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Lungs: clear without rhonchi or wheezes.
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Heart: RR, normal heart sounds, no murmur.
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Skin: no vesicular eruption typical of varicella, no areas of impetiginization.
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Extremities: capillary refill less than 2 seconds.
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