Assignment: Child Profile

Assignment: Child Profile
Assignment: Child Profile
Name: E.F Date: 01/17/2019
Sex: Female Age/DOB/POB: 6 Months / 12/06/2017/Miami, FL
SUBJECTIVE
Historian: Mother
Present Concerns/CC: “I’m here today for the 6 months check- up of my baby”
Child Profile:
6 months old infant brought by her mother. Information obtained by the mother.
Patient is breastfed 5-6 times daily. Her mother started to introduce puree diet made at home. Patient has 1-2 bowel movements daily and an average of 9-10 wet diapers. She sleeps 8-10 hours at night and takes 2 naps of approximately 1-2 hours during the day. Mother is the one who is caring for the patient at home. Patient is able to move front to back and back to front and sits well with slight support. Patient responds to mother’s voice, giggles, and babbles. Per mother, patient is not exposed to second hand smoking, rides on the back of the car with car seat facing backwards. No guns or pets at home and patient is kept in a hazard free environment.
HPI: (must include all components)
6-month-old female who presents with mother for her 6-month well-visit checkup. No past medical history or current health concerns
Medications:
None
PMHX:
Allergies: NKA
Medication Intolerances: None
Chronic Illnesses/Major traumas: None
Hospitalizations/Surgeries: None
Immunizations: up today
Family History
Mother- 27 years old. Alive and well
Father- 28years old. Alive and well
Social History
Patient lives with both parents. Mother took some time off from work to stay at home with the patient. Mother denies smoking, guns, pets, or violence at home.
ROS
General
Denies for fever, lethargy, difficulty arousing or irritability
Cardiovascular
Denies for cyanosis, swelling or activity intolerance
Skin
Denies rashes, urticaria, lesions or birthmarks
Respiratory
Denies cough, difficulty breathing or wheezing
Eyes
Denies strabismus, eye irritation or discharge
Gastrointestinal
Denies decreased appetite, reflux, burping or diarrhea
Ears
Denies for ear tugging or discharge
Genitourinary/Gynecological
Denies for anuria, changes in color of urine or discharge
Nose/Mouth/Throat
Denies nose congestion, nose bleeds, or mouth sores
Musculoskeletal
Denies for fractures or contractures
Breast
Denies for lumps
Neurological
Denies syncope, seizures, epilepsy or tremors
Heme/Lymph/Endo
Denies blood transfusions, inability to growth, or sweet odor of urine or sweat
Psychiatric
Denies difficulty falling asleep or staying asleep
OBJECTIVE
Weight
15 lbs
Temp 97.5 F Head circumference: 42 cm
Height
26 inches
Pulse 116 x’ RR: 21 x’
SpO2: 99% at Room air
General Appearance and parent?child interaction
Well- nourished, healthy looking patient held in arms by mother. Both look happy.
Skin
Skin is warm to the touch and dry. No rash, lesions or bruising.
HEENT
Head: Normocephalic head, oval shape and no traumas. Closed posterior fontanelle.
Eyes: Pupils PERRLA. Present red reflexes on both eyes
Ears: No tenderness. Pink tympanic membranes
Nose: Normal turbinates. Septum midline
Mouth: 2 bottom central incisors.
Throat: No erythema of exudates
Neck: Supple without masses or thyroid enlargement
Cardiovascular
Regular heart rate and rhythm. S1 and S2 present. No gallops, bruits or thrills present.
Respiratory
Unlabored respirations. Lungs clear in all lung fields.
Gastrointestinal
Soft abdomen without tenderness or guarding. Bowel sounds active and normal in all quadrants
Breast
Tanner stage 1.
Genitourinary
Tanner stage 1. No pubic hair, No rashes, no bruises or no lesions. Hymen intact.
Musculoskeletal
Full ROM of all extremities. Good muscle tone and strength
Neurological
Present Barbinski reflex. Patient turns toward finger rub. Maintains head control without assistance
Psychiatric
Smiling and easily comforted by mother
In-house Lab Tests – document tests (results or pending)
None
Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale
For adolescents (HEADSSSVG Assessment)
Assessment conducted during this visit: PEDS score of 0 (no concerns)
This assessment is performed by having parents fill out a questionnaire of 10 questions. It takes approximately 2 minutes to be completed. According to Woolfenden et al., (2014), this questionnaire is easy to understand to 95% of the parents regardless of their educational level or background. Its purpose is to discover concerns and address certain areas of development with the appropriate timely referrals for follow up.