GNT: Denies Sore throat. R e s p i r a t o r / : Ds^niea Cough cTtxuring during woking hours.

Cough occuiitiy during sleep, Wheezing or difticLiiiy breathing, Chest pain. GasfroJniestJnal: RGportg Nausea. Abdomtngl pajp. D e n i e s Vomiting. Cramping or bloating, Diarrhea. G c o l l o u r i f i a r Y ( M / F ) : Ropofis Dysuria: urination discQrnfon\yhile and att^r volfiinq. FreQueincy. so<rte trequency a t K | betUvettifig for the past .several wgjek^. Ftank onin: more muscio ache b<;hiriri i d t stjAid^f. Denies t^ioody, tea colored or darH urine. Mucufoskelettl: Dentes Mijscio aohas; hack pain. Pain. I m t e g u m e n t a r y ( S k i f i / B f e a s t ) ; Denies Rashes. | i t ^ e m a t o l o g i c / L y i n p l i a i r c / t r n r n u n o i o g l c : Denies recGr,! illru3ss (ever swollen glando. I N c u t o : Denies Behavior tussy inconsolable lethargic insomnia activity irjcreased/decreased i Oevolop'iiemai Delay I Seizure. :1 ,

Vtlaf Signs
Blood Pressure: 127 / 49 (neod !ir) @14-17 PulSii; 93t)pm teoip {tyinp)' Sy.SF/37.5c Woigm. 57to 2 0 2 / 26 9 8 k g ( 6 3 %!ie)

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Exam Findings

G e n - A p p e c r a n c o : Normal Appea/anca; wftii appearing, NutJitiot]; Groorrung; ActJvrty level, rer,por"!Sivenea|. Eyes: K'orniaf Red Reflox; Conjunctivao and lids; Pupil a i t e , symmetry, accomrnodation, rttaclion to light. I Ears, Nose, M b i r t h . T h r o a t : N^omtai External ears and nose. >io Discharge Clear Mucoid Bloody I Ter)dfimecs to Pri!patk)n; Tiirjsils, poslerior pharyrkx, hard & soft palate, oral m u c o s a , tongue; I MotJih/Thronf I no Erythema Exudate Vesicles Dry | Mucous t ^embrsnec. bindings. T m L R Goth I no Effusion Serous Bulging non fcryttJemstnus not ObscurerJ by Wax. I Neck; Normal Weok tiexibility. FindinQs; non Rigid no Cervical Lymphadonopathy. I Respiratory^ NonnarRespiratory effort: symmelo/ and eypansiort of <;he3t., Auscultation of lungs, I Cardiovascutgrr Norniai Auscuitatton. | G a s t r o i n t e s t i n a l : Nornial Atsdomlr-sal e x a m : Soft Nnn l e n d e r Wo HSM | non OistRnded no Decreased BS non Teixler n o no Guarding I no Organnrnegaiy | G c n i l o u n n a r y : ABNORMAi,. Findings: labia maiora are mildly er/thematous. Norma! Prepubertal external I genitalia: n o vaginal discharge. leSion,.bruises end the h y m e n is intact; Pr&pul>ertai introitus. | M u s c u l o s k o l e t a l : Nornnai Gait, and station; SpontatitKJus rnovofrtent/rangc of motion oi extreniitles. i S k i n : Nonnal vSkin tons, te>fturG, turgor, eiasticity, capillcuy filling; Inspection tor rasns, lesions. uJcers. I N e u r o l o g i c : Nonnal Findlncfs; Appropriate M o d o f r d t s . I A t t o r - c c i / K s y n i m m r y s e n s o f y or Motor Deficit.

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Medical Decision Making

Wilt no&ci to follow up o n the History Qiven by mother. Will file a O C P S rupan, although motrier states that s i l has Hied one. This is most likely a vaginitit; recommended sitz baths, will start Keflex suspension 500 m g t J pending the cutturR that was sot up in our otfice. Mothof fencourag&d to f/u with the child's P M D on 7/18/11. | DX 1; 599.0 URINARY T R A C T INFECTION U N 5 P E C ^ I

Pfan
Oesorifc)ed risks, ss it sxs of ir {creasing illnas^i CONDITION. Good