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
Present Concerns/CC: Im here today for the 6 months check- up of my baby
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 mothers 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
Medication Intolerances: None
Chronic Illnesses/Major traumas: None
Immunizations: up today
Mother- 27 years old. Alive and well
Father- 28years old. Alive and well
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.
Denies for fever, lethargy, difficulty arousing or irritability
Denies for cyanosis, swelling or activity intolerance
Denies rashes, urticaria, lesions or birthmarks
Denies cough, difficulty breathing or wheezing
Denies strabismus, eye irritation or discharge
Denies decreased appetite, reflux, burping or diarrhea
Denies for ear tugging or discharge
Denies for anuria, changes in color of urine or discharge
Denies nose congestion, nose bleeds, or mouth sores
Denies for fractures or contractures
Denies for lumps
Denies syncope, seizures, epilepsy or tremors
Denies blood transfusions, inability to growth, or sweet odor of urine or sweat
Denies difficulty falling asleep or staying asleep
Temp 97.5 F Head circumference: 42 cm
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 is warm to the touch and dry. No rash, lesions or bruising.
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
Regular heart rate and rhythm. S1 and S2 present. No gallops, bruits or thrills present.
Unlabored respirations. Lungs clear in all lung fields.
Soft abdomen without tenderness or guarding. Bowel sounds active and normal in all quadrants
Tanner stage 1.
Tanner stage 1. No pubic hair, No rashes, no bruises or no lesions. Hymen intact.
Full ROM of all extremities. Good muscle tone and strength
Present Barbinski reflex. Patient turns toward finger rub. Maintains head control without assistance
Smiling and easily comforted by mother
In-house Lab Tests document tests (results or pending)
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.
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