Blake Photo Time-Line

ONLC PEDIATRICS OCHSNER, BATON ROUGE REGION LA

Grondin, Blake John MRN: 12051461, DOB: 2/14/2020, Sex: M Acct #: 72011186970 Enc. Date 9/3/2020

Progress Notes (continued)

Progress Notes by Lois H. Gesn, MD at 9/3/2020 4:40 PM (continued) Heart sounds: S1 normal and S2 normal. No murmur. No friction rub. No gallop. Pulmonary: Effort: Pulmonary effort is normal. No respiratory distress. Breath sounds: Normal air entry. Wheezing (rare end exp wheeze) present. No rales. Abdominal: General: Bowel sounds are normal. Palpations: Abdomen is soft. There is no mass. Tenderness: There is no abdominal tenderness. There is no guarding or rebound. Genitourinary: Comments: Normal genitalia. Anus patent. Musculoskeletal: Normal range of motion. Comments: No hip click. Skin: General: Skin is warm. Turgor: Normal. Findings: No rash. Neurological: Mental Status: He is alert. Motor: No abnormal muscle tone. Primitive Reflexes: Primitive reflexes normal.

Assessment:

1. Encounter for routine child health examination without abnormal findings

Plan:

Blake was seen today for well child.

Diagnoses and all orders for this visit:

Encounter for routine child health examination without abnormal findings - DTaP HiB IPV combined vaccine IM (PENTACEL) - Hepatitis B vaccine pediatric / adolescent 3-dose IM - Pneumococcal conjugate vaccine 13-valent less than 5yo IM - Rotavirus vaccine pentavalent 3 dose oral

Chronic nasal congestion due to daycare exposure. Mild wheezing with no distress Rec normal saline drops, suction nose, keep house cool RTC for worsening wheezing or fever.

Electronically signed by Lois H. Gesn, MD on 9/3/2020 5:32 PM

Follow-up and Disposition History

Generated on 7/19/22 2:38 PM

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