PC: COMPLAINT- DURATION
HPC:
ODQ:
PREGNANCY HX: BOOKING WAS AT _, RETRO _, SICKLING _, ANC VISITS _,
DELIVERY HX: DELIVERED AT _, VIA _, APGARS _, _ NICU ADMISSION,
IMMUNIZATION HX: VIT K _, BCG SCAR _, IMMUNIZATION _, __CONFIRMED FROM MATERNAL AND CHILD RECORDS.
NUTRITIONAL HX: BREAST FEEDING WAS __ INITIATED WITHIN THE FIRST 30MIN OF LIFE, EXCLUSIVE BREAST FEEDING __ MONTHS, COMPLEMENTARY FEED STARTED AT __ MONTHS. CURRENTLY FEEDS FROM FAMILY POT,
DEVELOPMENTAL HX:
GROSS MOTOR:
FINE MOTOR:
SPEECH:
SOCIAL:
PMSHX: BLEEDING TENDENCIES __, PREV ADMISSION __, PREV SURGERIES __, TRANSFUSION __
DHX: CURR MEDS, OTC, HERBAL, ALLERGIES
FHX: HPT, DM
SHX: A __OCCUPATION__, LIVES AT __LOCATION__ WITH ___, ALCOHOL, SMOKING
OE: ADULT __GENDER__ IN NO OBVIOUS RESP DISTRESS NOR PAIN, NOT PALE, NOT JAUNDICE, AFEBRILE, HYD FAIR
RR: CHEST EXPANSION IS ADEQUATE AND SYMMETRICAL, AE ADEQUATE BIL, BS VESICULAR NO ADDED SOUND
CVS: S1 + S2 NO MURMUR
ABD: FULL, MWR, NON TENDER, NO MASSES NO ORGANOMEGALY
CNS: GROSSLY INTACT, GCS 15/15 CONSCIOUS AND ALERT, ORIENTED TO TIME PLACE AND PERSON
