– VITALS: Reviewed
– GROWTH CHART: Following growth curve well in all parameters.
– GEN: Normal general appearance. NAD.
– HEAD: NCAT.
– EYES: PERRL, red reflex present bilaterally. Light reflex symmetric. EOMI, with no strabismus.
– ENMT: TMs, nares, and OP normal. MMM. Normal gums, mucosa, palate. Good dentition.
– NECK: Supple, with no masses.
– CV: RRR, no m/r/g.
– LUNGS: CTAB, no w/r/c.
– ABD: Soft, NT/ND, NBS, no masses or organomegaly.
– GU: Normal genitalia.
– SKIN: WWP. No skin rashes or abnormal lesions.
– MSK: Normal extremities & spine.
– NEURO: MAE symmetrically. Normal muscle strength and tone.
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