Blake Photo Time-Line

ONLC PEDIATRICS OCHSNER, BATON ROUGE REGION LA

Grondin, Blake John MRN: 12051461, DOB: 2/14/2020, Sex: M

Acct #: 72013499100 Enc. Date 6/14/2021

Progress Notes (continued) Progress Notes by James A. Wayne Jr., MD at 6/14/2021 1:30 PM (continued) History reviewed. No pertinent past medical history.

Review of Systems Constitutional: Negative for activity change, appetite change and fever. HENT: Positive for nasal congestion, rhinorrhea and sneezing. Eyes: Positive for discharge. Respiratory: Positive for cough. Negative for wheezing. Cardiovascular: Negative for chest pain. Gastrointestinal: Negative for abdominal pain, constipation, diarrhea and vomiting. Musculoskeletal: Negative for myalgias.

Objective:

PHYSICAL EXAM: Vitals:

06/14/21 1344

Pulse: Resp: Temp: SpO2: Weight: Height: TempSrc:

104

24

99 °F (37.2 °C)

Tympanic

99%

11 kg (24 lb 4 oz)

2' 7.5" (0.8 m)

General: Alert and vigorous. Good color. No distress. Skin: red papules in perioral region, bilateral hands and feed with small red papules on lateral aspects of palmar and plantar surfaces, and a few papules on right elbow Eyes: No redness or injection. Discharge: crusted discharge in lashes bilaterally ENT: Ears: Normal pinna/lobes. Tympanic membranes clear bilaterally. Nasopharynx: Clear rhinorrhea and audible nasal congestion. Mouth/Throat: erythema and small red ulcers on tonsilar pilars. Tonsils, 1-2+, no exudate. Neck: Supple, with no masses. Full range of motion present. Lymphatic: No adenopathy in anterior cervical or posterior cervical lymph node regions. Lungs/Chest: Clear to auscultation bilaterally. No wheezes or crackles. Good air flow, and no retractions. Heart: Normal sinus rhythm and regular rate. No murmurs. Abd; Soft, NT, ND, +BS, no masses, no HSM

Electronically signed by James A. Wayne Jr., MD on 6/15/2021 9:44 AM

Follow-up and Disposition History

06/14/2021 1408 - James A. Wayne Jr., MD Dispositions:

Follow up if symptoms worsen or fail to improve. ·

Follow-up Information None Generated on 7/19/22 2:38 PM

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