Blake Photo Time-Line

ONLC PEDIATRICS OCHSNER, BATON ROUGE REGION LA

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

Acct #: 72010431850 Enc. Date 4/27/2020

Progress Notes (continued)

Progress Notes by Lois H. Gesn, MD at 4/27/2020 4:40 PM (continued) Author: Lois H. Gesn, MD Service: —

Author Type: Physician

Filed: 4/28/2020 8:03 AM

Encounter Date: 4/27/2020

Creation Time: 4/28/2020 8:00 AM

Status: Signed

Editor: Lois H. Gesn, MD (Physician)

Subjective:

Blake John Grondin is a 2 m.o. male here with maternal grandmother. Patient brought in for Well Child

History of Present Illness : Well Child Exam Diet - WNL - Diet includes formula Growth, Elimination, Sleep - WNL - Growth chart normal and sleeping normal Physical Activity - WNL - active play time Behavior - WNL -

Development - WNL -Developmental screen School - normal -home with family member Household/Safety - WNL - adult support for patient, appropriate carseat/belt use, back to sleep and safe environment

Review of Systems Constitutional: Negative for activity change, appetite change and fever. HENT: Negative for congestion and mouth sores. Eyes: Negative for discharge and redness. Respiratory: Negative for cough and wheezing. Cardiovascular: Negative for leg swelling and cyanosis. Gastrointestinal: Negative for constipation, diarrhea and vomiting. Genitourinary: Negative for decreased urine volume and hematuria. Musculoskeletal: Negative for extremity weakness. Skin: Negative for rash and wound.

Objective:

Physical Exam Constitutional: He appears well-developed and well-nourished. Non-toxic appearance. HENT: Head: Normocephalic and atraumatic. Anterior fontanelle is flat.

Right Ear: Tympanic membrane and external ear normal. Left Ear: Tympanic membrane and external ear normal. Nose: Nose normal. Mouth/Throat: Mucous membranes are moist. Oropharynx is clear. Eyes: Pupils are equal, round, and reactive to light. Conjunctivae, EOM and lids are normal. Neck: Normal range of motion. Neck supple. Cardiovascular: Normal rate, regular rhythm, S1 normal and S2 normal. Exam reveals no gallop and no friction rub. No murmur heard. Pulmonary/Chest: Effort normal and breath sounds normal. There is normal air entry. No respiratory distress. He has no wheezes. He has no rales. Abdominal: Soft. Bowel sounds are normal. He exhibits no mass. There is no hepatosplenomegaly. There is no tenderness. There is no rebound and no guarding. Genitourinary:

Genitourinary Comments: Normal genitalia. Anus patent. Musculoskeletal: Normal range of motion. He exhibits no edema. Generated on 7/19/22 2:38 PM

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