Case description for C-Takes documenting:
Setting: Outpatient.
Specialty: Pediatrics. 
Note detail level (1-5): 3.
Level of abbreviation (Low/Medium/High): Medium.

18 hour old infant male (Baby X), AGA 3214g born at 40+1 weeks on 0 Feb 2010 at 1400 with apgars of 8/9, routine NRP was performed. Mother is a 26 yo G3nowP3, A+, GBS+, RI, SVD w/ ROM <18 hours. PCN given x2, no other infectious risk factors. Pt requesting routine circ. Overnight: Newborn is breast feeding well, no other issues. Hearing test pending. Pre and post ds pending. Prob no TCB necessary. IMS pending. Wt DOL #2 pending. ABO RH+ not required.

Vit: T 98.2-99.6 HR 98-136 SPO2 97 RR 26-44
PE:
Head circ@birth: 33.5
Gen: Sleeping on initial exam, easily aroused, no acute distress.
Neuro: Moro, grasp, and sucking reflexes intact. Normal tone.
Optho: Red reflex present bilat.
Head: Fontanelle flat, mildly overriding sutures, no evidence of low set ears, holes, tags.
ENT: Patent nares, no flaring, no signs of cleft pallet. 
CV: No m/r/g, rrr. S1, S2 wnl. No cyanosis, cap refill wnl. 
Pulm: Ctab, no w/r/r. No accessory muscle recruitment. 
Abd: Soft, nbs, non tender, no hepatosplenomegally.
MSK: Unremarkable Otolinii/Barlow.
Gen/Uro: Normal appearing male gen.
Derm: No signs of jaundice, no rashes/lesions, no etn.

A/P: 
Newborn infant male in no acute distress. Unremarkable exam. Doing well.
- Plan circumcision for this AM.
- Counsel parents on wound care for circumcision.
- Plan to DC this PM pending normal routine discharge w/u.

