By Howard S. Becker, Blanche Geer, Everett C. Hughes, Anselm L. Strauss
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Clinical Case Studies for the Family Nurse Practitioner, First Edition. Edited by Leslie Neal-Boylan. © 2011 John Wiley & Sons, Inc. Published 2011 by John Wiley & Sons, Inc. 3°C (rectal). General: Alert baby; well-developed. Skin: Clear with no lesions noted; no cyanosis of skin, lips, or nails; no diaphoresis noted; good skin turgor. 5 cm). Eyes: Red reflex present bilaterally; pupils equal, round, and reactive to light; no discharge noted. Ears: Pinnae normal; tympanic membranes gray bilaterally with positive light reflex.
HEENT: Juancarlos’s head is normocephalic. 5 cm). Red reflexes are present bilaterally and pupils are equal, round, and reactive to light. There is no discharge noted. Pinnae are normal; tympanic membranes are gray bilaterally with positive light reflexes. Bony landmarks are visible, and there is no fluid noted behind the tympanic membrane. Both nostrils are patent. There is no nasal discharge; and there is no nasal flaring. Juancarlos’ mucous membranes are noted to be moist when examining his oropharynx.
Medications: Currently taking no prescription, herbal, or over-the-counter medications. Allergies: No known allergies to food, medications, environment. Birth history: Alicia was the product of a 38-week gestation. She was delivered via spontaneous vaginal delivery. Alicia’s mother had no falls, infections, or known exposures to environmental hazards. The only prescription medications taken during the pregnancy were prenatal vitamins. She did not use alcohol, tobacco products, or illicit drugs during the pregnancy.