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NAME: LAGRONE, MICHAEL, S M

ALLERGIES: WIC Participation:~s Vitamins/Medications: 0 No

ACC #: 34826.1 O.O.B.: 08/27/2012

HPl: Complaining of nasal congestion, cough, and low gj'ade temperature for a few days. ROS Resp: Negative for difficulty breathing GI: Negative for abdominal pain, vomiting, and diarrhea ENT: TM's clear bilaterally; nares with clear discharge; o ro phar-vnx moist, no lesions Resp: CTA throughout CV: RRR, no murmur G I: l~ bd 0 men soft, no in as ses j no HSM MS: No clubbing, cyanosis, or edema Skin: Normal temperature, diaper area,. slight papular rash noted Neuro: OTR's 2+ bilaterally; CN II-XII intact grossly; 5/5 muscle s t r anqt h R: Viral Syndrome/DIAPER RRSH

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MICHAEL

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PATIENi: LAGRONE,
(34826.1) DOS: '3/5/2013 DOT: 9/512013 LOC: CFP - Orange

C it Y <11: 00 )

TWELVE MONTH ASSESSMENT NUTRITIONAL ASSESSMENT: table foods t~IC- yes


at'

formula,

no
for

Meds/Vitamins-Nystatin candidal diaper rash

P: Symptomatic care discussed. Report new or worsening symptoms. F!U t~CC. --+-Refill Nystatin given to mom. Document Electronically Signed by Dawn Diomede, RRNP Finalized Time Stamp: 8!l9!2013
4:48:01 P

Medical Concerns:Mom is concerned about the care that child is receiving when at his father's house during limited visitation weekly. Mom states that log books s~ow that child has not been fed adequatelv or things that are age-;pprop~iate.
She is currently seekign help

from a child advocacy has DCF involved. Lead 1eve 1 visit)


(i f not

group and

done

at '3 rnth ----

Ai.I6 2

o an ~

DEVELOPMENT SCREEN: DDS II Walks without support - Yes Points - Yes Vocabulary - )4 words Well-developed pincer' gr'a:;p Stoops and recovers-Yes PHYSICAL EXAM: O=Normal X=Abnormal Wt 25 l.ile length 75 '1.ile HC 75 '1.ile Skin - Cleal"' with no rashe s, lesions noted on exam Head - I] Eyes/RR - 0 ENT - 0 Teeth-O Nodes - 0 Chest/Lungs - 0
Head - 0

Yes,

Child's Name: H~01tU

LAS4 uyt.q

Name of Person Bringing Child:

rYJ Ot~ (I -?aop:a5


Relation to Child: _.........:.(Yi---..:.:::O:..:.fJ/1:....:..
_ ;V Known Drug Allergies: ----~~~------

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In

Reason for Visit: o Sick 0 Well 0 Recheck ,Ovaccine Only Symptoms: _

Under 12 months: ormula Type of formula: ---1~:::.:..!i..e::~~U _

Abdomen .- 0 Genitalia - Mild erythe~atou5