Dra Verónica Alicia Gómez Hernández
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Date of Birth:
November 15th 2005
Place of birth:
1st office visit : December 14th , 2005
Age: 01 month
Weight 08 pounds 13 ounces Length
52.5 cms Head Circ 36.7
cm
Physical examination:
normal
Development Motor good muscular
tone and force
Social seems comfortable with
foster mother
Language: just vocal sounds
Labs: VDRL negative
HBs Ag Hep B
negative
HIV 1 y 2 negative
TSH ( 4 days of life) 12uUI /ml
normal up to 20 uUI/ ml
Dx Healthy baby
Tx: SMA gold baby feeding formula
Comments: This is the first office visit of Waymer,
from the data of the born certificate I can say that he increase
02 pounds this first month of life,
GOOD!! His weight, size and head
circumference plus neurological development are all normal for age.
Medico y Cirujano
PEDIATRA



