PMD:
Reason for consultation:
HPI:
PMHx/PSurg Hx:
Family Hx:
Meds:
Allergies:
Vaccines:
Menstrual Hx: Menarche- ___, ___ periods/year, __ days
Psychosocial History:
Home/Neighborhood/Exposure to Violence:
Education/Employment:
Activities:
Drugs/Depression:
Diet: meat intake; milk intake
Sex:
Sleep:
Body Image:
Review of systems:
Constitutional: denies fevers, feels generally healthy
Respiratory: Denies asthma, no cough, no dyspneaNo SOB.
GU: Denies any dysuria, no vaginal discharge.
CVS: Denies chest pain, no palpitations.
GI: No Abd pain, no nausea, no vomiting, no diarrhea, no dyspareunia
MSK: No swelling, no redness, no joint pain.
Neuro: Denies headache, no seizures, visual problems.
Integument: Denies rash,
Physical Examination:
Ht: cm ( %) Wt: kg ( %) HC: cm( %) BMI: kg/m2 ( %)
General appearance: Alert, active, well hydrated, not in acute distress
Eyes: PERLA & EOMI
Ears: No erythema, no discharge, TMs appears normal
Nose: nasal mucosa not congested
Throat: no oral lesions, no pharyngeal erythema, no tonsillar enlargement
Neck: no cervical adenopathy
Chest: symmetric chest expansion, no retractions
Lungs: Good air entry, clear breath sounds, (-) wheezing/rhonchi/crackles
Heart sounds: Regular rate and rhythm, distinct heart sounds, no murmurs noted
Abdomen: (+) BS, soft, non-tender, no organomegaly, no CVA tenderness.
Extremities: good pulses, good capillary refill
Skin: normal
Neuro: Grossly normal
Assessment: 1 yo HF HM BF BM, healthy, growing and developing well.
Plan:
Tdap
Menactra
HPV#1
Influenza
Cbc, lipid profile, urinalysis, RPR, Quantiferon
Hearing and vision
Declines Accepts HIV testing
Condoms given
Side effects of vaccines discussed and when to seek medical attention.
Anticipatory guidance discussed
Healthy diet 5-2-1-0, regular exercise
Reduce juice/sugary beverages
Referrals given: Dental
RTC in 3 months for WCC
Seen and examined with attending Dr. Collier