Well Child Check 8-11 year old

8-11 YEARS
 
  SUBJECTIVE:
  _ here for well child check. No parental or patient concerns at this time.

Here with parent: _
  REVIEW OF SYSTEMS:
  - Diet: No concerns.
  - Fast food, soda, juice intake: _
  - Calcium intake: _
  - Dental: + brushes teeth. Sees the dentist regularly.
  - Sleep concerns (duration, snoring, bedtime): None.
  - Elimination concerns (including menses in females): _
  PM/SH:
  Normal pregnancy and delivery. No surgeries, hospitalizations, or serious illnesses to date.
  DEVELOPMENT:
  - In _ grade. School is going well. No parental or teacher concerns about behavior.
  - Friends/hobbies (i.e. after school activities): _
  - Physical activity (and safety): _
  - Screen time: _
  SOCIAL:
  - Noteworthy social stressors: _
  - No smokers in the home.
  - No TB or lead risk factors.
  IMMUNIZATIONS:
  - Up to date.
  OBJECTIVE:
  - VITALS: _
  - WEIGHT: BMI _
  - 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 genitalia, Tanner stage _
  - SKIN: WWP. No skin rashes or abnormal lesions.
  - MSK: No deformities or signs of scoliosis. Normal gait. No clubbing, cyanosis, or edema.
  - NEURO: Normal muscle strength and tone. No focal deficits.
  LABS/STUDIES:
  - Urine dip normal.
  - Hearing screen normal.
  - Snellen testing: _
  ASSESSMENT/PLAN:
  * Healthy _ yo child
  - CBC ordered. No indication for DM screening.
  - Check lipid panel between 9-11 yo, repeat 18-21 yo.
  - Screen for depression _ >12 yo.
  - Follow in one year, or sooner PRN.
  - ER/return precautions discussed.
  * Vaccines today:
  - Influenza, HPV (0, 1-2, and 6 months, starting at age 9), Tdap (11-12), Meningococcal (11-12)
  * Anticipatory guidance (discussed or covered in a handout given to the family)
  - Puberty
  - Peer pressure, bullying, communication with teachers, violence prevention
  - Seat belts, helmets and safety gear, sunscreen
  - Internet safety, limiting screen time
  - Appropriate discipline for age
  - Healthy food, exercise, good dental hygiene
  - Eliminating guns from the home, or locking bullets separately
  - Hazards of second hand smoke