Well child – 2 mo

Sep 16, 2018 • Mark Morgan

categories: Pediatrics

HISTORY:

provided by parent provided by other unobtainable d/t parental anxiety and/or lack of knowledge interpretation provided by family member interpretation provided by MA
Newborn screening:

unknown Nml
Hearing screening:

unknown Nml

SPECIAL NEEDS:

none specialty
SOCIAL HISTORY:

no changes child care housing single parent working parent siblings maternal depression

REVIEW OF SYSTEMS
Interval change:

doing well, no changes since last visit no illnesses or injuries no specific concerns raised no visits to health care providers, facilities questionnaire provided & reviewed

Nutrition:

no concerns breast formula
Urination:

no concerns >6 wet diapers per day
Stooling:

no concerns
Sleep:

no concerns crib

GROWTH:

chart provided, reviewed, developing well
MILESTONES:

lifts head prone props up on hands holds head briefly upright pays attention to sounds & sights indicates boredom w/o activity smiles responsively looks at caregiver shows pleasure with parents coos and vocalizes reciprocally different cries for different needs

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Appearance:

well-appearing active, interactive no distress uncooperative with exam
Skin:

pink, normal turgor no rashes no bruises erythema toxicum milia
Head:

no skull deformities normal fontanells
Eyes:

blinks to light, red reflex bil, appears to see palpebral exudate
Ears:

normal position, appears to hear
Nose:

nares patent
Mouth:

oral mucosa moist & without lesions, tongue normal in appearance/size & with good movements, normal palate
Throat:

patent pharynx w/o swelling or exudates
Neck:

supple, symmetrical ROM, turns head side to side
Chest:

unlabored respirations, symmetric chest expansion, clear and equal breath sounds bilaterally
Heart:

regular rate & rhythm, no murmurs
Abdomen:

soft, nondistended, nontender, no obvious palpable masses, bowel sounds normal
Genitalia:

normal appearance uncircumcised circumcised testes down bilaterally
Extremities:

symmetrical FROM, hips w/ good abduction w/o clicks
Peripheral vascular:

femoral pulses present & equal, normal perfusion
Back:

normal spine no sacral dimpling
Neuro:

normal reflexes, normal & symmetrical tone/strength

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LABORATORY/OFFICE DIAGNOSTICS:

none normal non-specific changes official report to follow pending

IMMUNIZATION:

per schedule deferred declined

OUTSIDE ORDERS/REFERRALS:

none laboratory studies diagnostic studies specialty WIC

DISCUSSED AND/OR HANDOUT GIVEN/OFFERED:

exam findings & recommendations signs of illness diagnostic studies development, growth, safety burns, plastic bags, crib safety, back to sleep nutrition, choking, no bottle in bed tummy time, skin care temperament, hold, cuddle, rock given opportunity to ask questions and state concerns verbalized understanding of instructions & POC

FOLLOW UP:

4 months of age, sooner if concerns arise

Well child – 2 mo

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