celestino.docx

8/16/2019 CELESTINO.docx

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ri6e "ith viand )er *ea; "ith !na6;! in +et"een? and good a6tivit& >de!6ri+ed +& *other a!)la&5$l and a6tive.

Fe" ho$r! )riot to 6on!$lt, "hile )atient "a! on her "al;er, )atient "a! o$t o5 +alan6e de!6ri+ed a! t$*ao+ $ng "al;er ;a!a*a !i +a+& on her right !ide. 9a+& "a! 6arried+& *other and "a! noted to +e "ea; loo;in, a"a;e +$t )re5rerred to +e l&ing do"n. There"a! $)"ard rolling o5 e&e+all! "ith t"it6hing o5 $))er and lo"er e:tre*itie!, "ith 6ir6$*oral

6&anoi!i, no drooling o5 !alive la!ting 5or '1 !e6ond!. There "a! no lo!! o5 6on!6io$!ne!!. No6on!$ltation "a! done. N *edi6ation! .

at +irth? 7-'7 8ealth Center

MMR '!t do!e 7-'39C= At +irth0 7-'7 8ealth Center

Ne#$orn Screenin%: Done on 7'-'3 at FEU0NRMFOto&co'stic Test: Done on 7'7'3 at FEU0NRMF

DEELO"MENTAL MILESTONES:

NUTRITIONAL HISTORY:"&tient is $re&s(ed (rom $irth to )resent (or *+,-. min'tes e&ch $re&st

e/er0 1 ho'rs2 She str&ted com)3ement&r0 (eedin% &t 4months #ith55552 Shecons'mes + t&$3es)ons o( rice #ith /i&nd e/er0 me&3 #ith sn&c6s in $et#een2

"HYSI!AL E7AMINATION

Gener&3 S'r/e0: a"a;e, a6tive, "ith good 6r& and ree:e!, 5e+rile, h&drated, not in6ardiore!)irator& di!tre!! "ith the 5ollo"ing vital !ign!CR RR Te*) 2/./°C 9 '3/1 gra*! >% !6ore G 02 >!t$nted, "a!ted??8C CC AC - 6* 9L 2/ 6*


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HEENT: )in; )al)e+ral 6onB$n6tiva, "hite !6lera, +ilateral, "ell05or*ed )inna, "ith !;in tagon le5t tragal area, )atent ear 6anal!, )atent no!tril!, inta6t li)! and )alateNec6: !$))le, no )al)a+le *a!!e!, no l&*)h node!, no 6re)itation!, no li*itation o5 *ove*ent!hest: thin 6he!t "all, !&**etri6al 6he!t e:)an!ion, no retra6tion!, 6lear +reath !o$nd!"ith good air entr&

He&rt: ad&na*i6 )re6ordi$*, ta6h&6ardi6, reg$lar rh&th*, no *$r*$rA$domen: Slightl& glo+$lar, dr& inta6t $*+ili6al !t$*), no di!6harge, non er&the*ato$!,non 5o$l !*ellingH !o5t, nor*oa6tive +o"el !o$nd!, no organo*egal&, no *a!!e!S)ine: !traight, *idline, no t$5t! o5 hairGenit&3i&: nor*al loo;ing 5e*ale e:ternal genitaliaRect'm: )atent anal ori6e, no )erianal ra!he!E8tremities: no gro!! de5or*itie!, 5$ll and e$al )$l!e!, CRTJ !e6ond!S6in: #ith intertri%o &nd r&shes on on 3'm$&r &re&Re9e8: >@? @? @? Moro, >@? Rooting, >@? 9a+in!;iMenin%e&3 Irrit&tion: No n$6hal rigidit&, no Kernig !ign, No 9r$%in!;i

NEUROLOGI! E7AMNINATION:!ere$r'm: a"a;e, a6tive, "ith good 6r& and ree:e!!ere$e33'm: no n&!tag*$!!N I : t$rn! head to the !*ell o5 *il; II '0 ** )$)il! e$all& rea6tive to light III, IV, VI inta6t e:trao6$lar *$!6le! V good !$6;, )o!itive 6orneal +lin; ree: VII no 5a6ial a!&**etr& VIII inta6t gro!! hearing, t$rn! e&e! to !o$nd! I, )o!itive gag ree: I *ove! head 5ro* !ide to !ide II tong$e at *idline

ASSESSMENT: TC Neonatal Se)!i!, Earl& On!et

"LAN:


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Dr2D&c'3&Gen'ino"&n%i3in&nA;'inoAn%e3es

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