Pediatric Assessment Essay

Pediatric Assessment

Patient is a four year old male, no known allergies to food or medication. Currently lives his with mother and father, a full time nanny, and an older sister which visits on alternating weekends. He is 42 inches tall, and 34 pounds with all limbs proportional and symmetrical. Primary language of family is English. All adults in the family are smokers that smoke outdoors. Patient is currently up to date on all immunizations.

Vital signs are: Temperature – 98.2, Pulse – 100, Respirations – 20, B/P – 94/58, O2 Saturation – 99%, Pain – 0.

Patient’s head is round and proportional to the body, with fused fontanels. Circumference of head is 20.5 inches. PERRLA with zero complaints of vision problems or eye pain. Ears show no signs of inflammation, redness, or discharge. Patient denies any pain or tenderness of the ears. Nares are symmetrical, with no signs of discharge or inflammation. Smile is symmetrical with full set of primary teeth. Throat is pink and moist in appearance, with no signs of irritation or inflammation. Tongue has full range of motion. No complaints of pain from mouth or throat. Patient reports equal sensation to touch on both cheeks. Neck has full range of motion, no JVD, and no pain reported. Zero signs of inflammation or tenderness upon palpation of cervical lymph nodes.

Lungs are clear to auscultation and chest has symmetrical expansion during respirations. Chest circumference is 20.6 inches. Zero complaints of cough or difficulty in breathing, even with exertion. Heart sounds are steady, no unusual noises noted. Patient has no complaints of pain. Capillary refill less than three seconds.

Bowel sounds noted in all four abdomen quadrants. No discoloration or distention of the abdomen noted visually. Abdomen was soft upon palpation with no pain or discomfort. Patient is toilet trained with no reports of