COMPREHENSIVE
Subjective:
Age:
Chief Complaint:
History of Present Illness:
Past Medical History:
Past Surgical History:
Medications (Med, Dosage, Frequency, Indication, Last dose):
Over the Counter/Herbal Supplements:
Allergies:
Active Problem List:
Immunizations:
Social History:
Food insecurity - denies
Economic concerns - denies
Diet – does well eating all food groups per mom. Drinks 4-6 oz of juice daily along with cow’s
milk (whole) and water.
Sleep – 8-10 hours per night with daily nap
Safety:
Do you feel safe at home? YES
Concern for abuse? NO
Family History:
Mother: Asthma, depression
Father: none known
Brother: none known
Maternal Grandmother: Stroke, bell’s palsy
Maternal Grandfather: COPD
Paternal Grandmother: none known
Paternal Grandfather: none known
Review of Systems: - Answered by mother
GENERAL: Patient reports overall good health. Patient reports regular sleep pattern and denies
recent weight gain or loss. Denies pain or recent injury. Patient denies recent fever and chills.
COMPREHENSIVE NOTE
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SKIN: Denies changes to skin/dry skin/dry hair/itching. Denies changes in skin pallor. Denies
rashes or lesions. Denies changes to moles, denies lumps or bumps. Denies changes to nail bed
texture/color.
HEENT: Denies headache. Denies head injury. Denies trauma. Denies eye pain/tearing/changes
to vision/double vision/blurry vision. Denies watery eye discharge. Denies ear
pain/discharge/changes to hearing. Denies stuffiness/sinus pressure/nasal discharge. Denies
nose bleeds. Denies sore throat /hoarse voice. Denies pain or difficulty swallowing. Denies
dental pain/changes in dentation. Denies use of corrective lenses.
NECK: Denies stiffness/pain. Denies lymphadenopathy.
CARDIAC: Denies chest pain. Denies swelling in upper/lower extremities.
RESPIRATORY: Denies cough/sputum discoloration. Denies difficulty breathing. Denies
wheezing/painful breathing with rest/normal activity/exertion. Denies history of asthma/OSA.
GI: Appetite good. Denies nausea/vomiting/dyspepsia/hematemesis/jaundice. Denies abdominal
pain. Denies change in bowel pattern. Denies diarrhea/constipation/hematochezia.
GU: Denies dysuria/urgency/frequency/incontinence. Denies hematuria. Denies urethral
discharge.
MUSKULOSKELETAL: Denies pain. Denies history of fractures/bone pain. Denies edema.
Reports full range of motion.
NEUROLOGICAL: Denies seizures/loss of consciousness/numbness and
tingling/tremors/muscle weakness. Denies memory loss/change in speech. Denies changes to
balance.
HEMATOPOIETIC: Denies bleeding/bruising/anemias.
ENDOCRINE: Denies polyuria/polyphagia/polydipsia. Denies heat/cold intolerance. Denies hair
loss.
PSYCHOLOGICAL: Denies changes to mood or activity level.
Objective Data:
Vital Signs:
Physical Exam:
GENERAL: Healthy appearing male well-nourished in no acute distress. Alert and oriented X 3.
SKIN: Pink, warm, intact skin. Nails without clubbing, cyanosis. No rashes/lesions. Anterior and
posterior fontanel closed. No plagiocephaly.
COMPREHENSIVE NOTE
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HEENT:
H: Head and scalp normocephalic without lesions. Hair of average texture. Relaxed facial
expression, symmetrical facial features.
E: Visual fields full by confrontation. Conjunctiva is pink and moist, sclera white, PERRLA.
EOMS intact. Disc margins sharp, without hemorrhages, or exudates. No arteriolar narrowing or
A-V nicking. No exotropia or exotropia.
E: Ear canals pink, dry, and intact upon visualization with otoscope with mild cerumen.
Tympanic membranes pearly gray, no bulging or discharge with a sharp light reflex. Hearing is
grossly intact. Responds to loud noise.
N: Nose symmetrical and midline. Mucosa and inferior turbinates pink, moist, and intact
bilaterally. Septum midline. Nasal cavities patent bilaterally.
T: Tonsils grade 2+, with no exudate. Posterior pharynx appears pink without exudate. Mucous
membranes pink and moist. Tongue midline. Dentition good for age. Uvula midline.
NECK: Neck supple. No JVD. No carotid bruits. Trachea midline. Thyroid isthmus not palpable,
lobes not felt, no nodules palpated. Neck ROM full. No torticollis.
BREASTS: Symmetric and smooth. No masses or nodules.
CARDIAC: Apical impulse barely palpable in the 4th left intercostal space. S1 and S2 heard with
normal rate and rhythm. No murmurs, clicks, rubs, or adventitious sounds auscultated.
RESPIRATORY: Chest expansion symmetrical. Respirations even and unlabored. No dullness
during percussion over lung lobes. Resonance upon percussion over posterior and anterior chest.
Breath sounds clear bilaterally in all lung lobes. Vesicular with no added sounds.
GI: Non-distended. Bowel sounds active and heard in all four quadrants. No bruits. Soft and
nontender to palpation. No masses or hepatosplenomegaly.
EXTREMITIES: No cyanosis, clubbing or edema. Calves supple, nontender. Radial, brachial,
dorsalis pedis, posterior tibialis pulses strong and intact bilaterally.
GU: Tanner stage 1. Circumcised penis. No penile discharge or lesions. No scrotal swelling or
discoloration. Tests descended bilaterally, smooth, without masses. Epididymis nontender. No
inguinal or femoral hernias.
MUSKULOSKELETAL: No joint deformities or swelling on inspection and palpation. No joint
pain. Demonstrates full active ROM in all joints; extremity strength 5+/5+. Extremity reflexes
2+/4+.
ENDOCRINE No occipital, auricular, cervical, submandibular, submental, or clavicular
lymphadenopathy.
COMPREHENSIVE NOTE
NEUROLOGICAL: Alert and oriented to person, place, and time. Appropriate for
developmental age. Cranial nerves II – XII intact. Gait normal for developmental age. Newborn
reflexes not present (moro, stepping, rooting, startle, blink, sucking, extrusion)
PSYCHOLOGICAL: Behavior and thought process normal for developmental age.
Diagnostic Testing:
Differential Diagnoses:
Preventative Screening:
Impression/Report/Plan/Patient Education
New Prescription from Current Encounter:
Medication Education:
Follow-up/New Appointments:
All questions and concerns were answered best of my ability. Educated to follow-up if new
concerns arise or in three months for next well-child visit.
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