Health Maintenance Exam

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General: Appears age appropriate.
Skin: Normal turgor and without lesions.
Head: ***<1 yr - Normocephalic with age appropriate fontanelles./>1 yr - Normocephalic.***
Eyes: Conjunctivae non-injected; sclerae anicteric; extraocular movements intact; pupils equal, round, and reactive to light. ***<1yr - Red reflex present bilaterally./1-4 yr - Red reflex present bilaterally. Symmetric light reflex./>5 yr - Symmetric light reflex, normal fundi.
ENT: Tympanic membranes gray, sharp landmarks. Nose clear. Palate is complete. Tonsils non-inflamed bilaterally.
Lymph Nodes: No significant lymphadenopathy.
Thyroid: No thyromegaly; trachea midline without masses.
Breasts: Without lesions or drainage.
Peripheral Vessels: Normal pulses and perfusion.
Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs.
Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds.
Abdomen: Soft, without organomegaly. Bowel sounds normal. Nontender without rebound. No masses palpable. No distention.
Genitalia: ***Normal male external genitalia; testes descended bilaterally; no hernia./Normal female external genitalia.***
Tanner: Tanner stage ***I/II/III/IV/V***
Spine: Straight with no lesions.
Joints: <4 months - Hips with full range-of-motion; negative Barlow and Ortolani./>4 months - Full range-of-motion about all joints.
Extremities: No clubbing, cyanosis, or edema. Normal upper and lower extremities.
***Gait: Normal and appropriate gait for age.***
Mental Status: Alert, oriented, in no distress. Appropriate for age.
Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age.

Health Maintenance Exam

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