venturafamilymed
Sep 8, 20212 min
SUBJECTIVE:
7 yo _ here for well child check. No parental or patient concerns at this time.
REVIEW OF SYSTEMS:
- Diet: No concerns.
- Fast food, soda, juice intake: _
- Calcium intake: _
- Voiding/stooling: No concerns.
- Dental: + brushes teeth. Sees the dentist regularly.
- Behavior: No concerns.
PM/SH:
Normal pregnancy and delivery. No surgeries, hospitalizations, or serious illnesses to date.
DEVELOPMENT:
- In _ grade. School is going well.
- Has friends.
- After-school activities: _
- Physical activity (and safety): _
- Screen time: _
- Does chores when asked.
- Knows address and home phone number.
- Prints letters without problems.
SOCIAL:
- Noteworthy social stressors: _
- No smokers in the home.
- No TB or lead risk factors.
IMMUNIZATIONS:
- Up to date.
OBJECTIVE:
- VITALS: _
- GEN: Normal general appearance. NAD.
- HEAD: NCAT.
- EYES: PERRL, red reflex present bilaterally. Light reflex symmetric. EOMI.
- ENMT: TMs and nares normal. MMM. Normal gums, mucosa, palate, OP. Good dentition.
- NECK: Supple, with no masses.
- CV: RRR, no m/r/g.
- LUNGS: CTAB, no w/r/c.
- ABD: Soft, NT/ND, NBS, no masses or organomegaly.
- GU: Normal _male genitalia. Testes descended bilaterally.
- SKIN: WWP. No skin rashes or abnormal lesions.
- MSK: No deformities. Normal gait. No clubbing, cyanosis, or edema.
- NEURO: Normal muscle strength and tone. No focal deficits.
GROWTH CHART: Following growth curve well in all parameters. BMI at _ percentile.
LABS/STUDIES:
- Urine dip normal.
- Hearing screen normal.
- Snellen testing: _
ASSESSMENT/PLAN:
* Healthy 7 yo child
- CBC ordered. No indication for a lipid panel or DM screening.
- Follow up at 8 years of age, or sooner PRN.
- ER/return precautions discussed.
* Vaccines today:
- Influenza
- None
* Anticipatory guidance (discussed or covered in a handout given to the family)
- Safety: Street safety, strangers, gun safety, helmets and safety equipment.
- Booster seat required by law until 8 yrs old or 4’9”
- Food and exercise: Limiting juice and junk/fast food, exercise.
- Memorize name, address, and phone number.
- School: Communicate with teachers, discuss peer pressure and bullying, internet safety.
- Speech: Importance of reading, limiting screen time.
- Dental care and fluoride; dental visits
- Hazards of second hand smoke