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Well child note

by Mark Morgan on April 12, 2010HISTORY OF PRESENT ILLNESS: ***age*** old child presenting for a health maintenance examination. There are no acute concerns today. Diet: ***Breastfeeding/Whole milk/1% milk/Skim milk/Formula feeding using ---/Combination of breast and formula using ---*** normal volumes for age. Additional diet: ***rice cereal/pureed fruits/pureed vegetables/pureed meats/soft fruit/soft vegetables/soft meat/finger foods/solids*** Sleep: Child is sleeping ***normally for age/with days and nights reversed/more than four consecutive hours***. The child ***sleeps on back/sleeps on side/sleeps on back or side/ sleeps ON STOMACH***. Elimination: Child is having ***normal urine and stool/constipated stools***. Health maintenance screening: Car safety: Child ***has car seat and uses it always/is rear facing/is in middle position of back seat/car seat has been safety checked by certified inspector/has car seat and uses it sometimes/has NO CAR SEAT/uses age, weight and size appropriate restraints*** Lead: ***no lead risks/moved from foreign country/major metropolitan area within 12 months receives governmental assistance/lives in or regularly visits building built before 1950 lives in or regularly visits building built before 1978 with ongoing repairs/has housemate or playmate diagnosed with lead poisoning*** Close contact with person with TB, live in area where TB is common, recent immigrant? ***yes - testing recommended/no*** Growth: ***is normal/is abnormal ---*** Development: ***Normal as per Ireton Child Development Screen/Abnormal ---*** All systems reviewed and negative except as mentioned in the History of Present Illness. PHYSICAL EXAMINATION: General: Well developed, well nourished age-appropriate child in no acute distress. Vitals noted and stable. Skin: Normal turgor and without lesions. Head: Normocephalic with age appropriate fontanelles. Eyes: Conjunctivae not injected; extraocular movements intact; pupils equal, round, and reactive to light. Red reflex present bilaterally. ENT: Tympanic membranes gray, sharp landmarks. Nose clear. Palate is complete. Lymph Nodes: No significant lymphadenopathy. Thyroid: No thyromegaly; trachea midline without masses. Breasts: Without lesions or drainage. Cardiovascular: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. No clubbing, cyanosis, or edema. Extremities are warm and well perfused and capillary refill is less than two seconds. Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds. Abdomen: Soft, nontender and nondistended without organomegaly. Bowel sounds normal. No masses palpable. Genitalia: ***Normal female external genitalia/Normal circumcised male external genitalia; testes descended bilaterally; no hernia/Normal uncircumcised male external genitalia; testes descended bilaterally; no hernia*** Tanner stage ***I/II/III/IV/V*** Spine: Straight with no lesions. Joints: ***negative Barlow and Ortolani (

in Pediatrics

Tagged as: health-maintenance

HISTORY OF PRESENT ILLNESS:
***age*** old child presenting for a health maintenance examination. There are no acute concerns today.
Diet: ***Breastfeeding/Whole milk/1% milk/Skim milk/Formula feeding using —/Combination of breast and formula using —*** normal volumes for age.
Additional diet: ***rice cereal/pureed fruits/pureed vegetables/pureed meats/soft fruit/soft vegetables/soft meat/finger foods/solids***
Sleep: Child is sleeping ***normally for age/with days and nights reversed/more than four consecutive hours***. The child ***sleeps on back/sleeps on side/sleeps on back or side/
sleeps ON STOMACH***.
Elimination: Child is having ***normal urine and stool/constipated stools***.
Health maintenance screening:
Car safety: Child ***has car seat and uses it always/is rear facing/is in middle position of back seat/car seat has been safety checked by certified inspector/has car seat and uses it sometimes/has NO CAR SEAT/uses age, weight and size appropriate restraints***
Lead: ***no lead risks/moved from foreign country/major metropolitan area within 12 months
receives governmental assistance/lives in or regularly visits building built before 1950
lives in or regularly visits building built before 1978 with ongoing repairs/has housemate or playmate diagnosed with lead poisoning***
Close contact with person with TB, live in area where TB is common, recent immigrant? ***yes – testing recommended/no***
Growth: ***is normal/is abnormal —***
Development: ***Normal as per Ireton Child Development Screen/Abnormal —***
All systems reviewed and negative except as mentioned in the History of Present Illness.
PHYSICAL EXAMINATION:
General: Well developed, well nourished age-appropriate child in no acute distress. Vitals noted and stable.
Skin: Normal turgor and without lesions.
Head: Normocephalic with age appropriate fontanelles.
Eyes: Conjunctivae not injected; extraocular movements intact; pupils equal, round, and reactive to light. Red reflex present bilaterally.
ENT: Tympanic membranes gray, sharp landmarks. Nose clear. Palate is complete.
Lymph Nodes: No significant lymphadenopathy.
Thyroid: No thyromegaly; trachea midline without masses.
Breasts: Without lesions or drainage.
Cardiovascular: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. No clubbing, cyanosis, or edema. Extremities are warm and well perfused and capillary refill is less than two seconds.
Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds.
Abdomen: Soft, nontender and nondistended without organomegaly. Bowel sounds normal. No masses palpable.
Genitalia: ***Normal female external genitalia/Normal circumcised male external genitalia; testes descended bilaterally; no hernia/Normal uncircumcised male external genitalia; testes descended bilaterally; no hernia***
Tanner stage ***I/II/III/IV/V***
Spine: Straight with no lesions.
Joints: ***negative Barlow and Ortolani (<4 months)/Full range-of-motion about all joints.***
Extremities: Digits and nails are normal.
Mental Status: Alert, oriented, in no distress. Appropriate for age.
Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age.
ASSESSMENT/PLAN:
#1 Normal growth and development, health maintenance exam
Age-appropriate injury prevention and health promotion issues discussed. Discussed after hours and emergency medical care. Immunizations given. Side effects, risks, and benefits of immunizations discussed. Return for health maintenance visit at *** of age or sooner should concerns arise.