HISTORY:

provided by parent provided by other unobtainable d/t parental anxiety and/or lack of knowledge interpretation provided by family member interpretation provided by MA
SPECIAL NEEDS:

none specialty
SOCIAL HISTORY:

no changes child care housing single parent working parent siblings

REVIEW OF SYSTEMS
Interval change:

doing well, no changes since last visit no illnesses or injuries no specific concerns raised no visits to health care providers, facilities questionnaire provided & reviewed
Nutrition:

no concerns
Elimination:

no concerns

GROWTH:

chart provided, reviewed, developing well
MILESTONES:

stands alone, cruises points, bangs toys together, drinks from cup, feeds self ways bye-bye, looks for dropped or hidden objects, cries when parent leaves, plays peekaboo imitates vocalizations, speaks 1 to 2 words, follows simple directions

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Appearance:

well-appearing active, interactive no distress uncooperative with exam
Skin:

pink, normal turgor no rashes no bruises
Head:

no skull deformities plagiocephaly
Eyes:

red reflex bil, ocular alignment appears normal
Ears:

appears to hear normal canals & TMs
Nose:

normal exam
Mouth:

oral mucosa moist & without lesions teeth present, no caries
Throat:

w/o swelling or exudates
Neck:

supple, no LAD
Chest:

unlabored respirations, symmetric chest expansion, clear and equal breath sounds bilaterally
Heart:

regular rate & rhythm, no murmurs
Abdomen:

soft, nondistended, nontender, no obvious palpable masses
Genitalia:

normal appearance uncircumcised circumcised testes down bilaterally
Musculoskeletal:

symmetrical FROM, normal spine
Neuro:

normal reflexes, normal & symmetrical tone/strength

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LABORATORY/OFFICE DIAGNOSTICS:

Hgb/Lead normal Hgb/Lead to be ordered per WIC

IMMUNIZATION:

per schedule deferred declined

OUTSIDE ORDERS/REFERRALS:

none laboratory studies diagnostic studies specialty WIC

DISCUSSED AND/OR HANDOUT GIVEN/OFFERED:

safety, childproof home, bike helmet, poisons, water safety, sunscreen age-appropriate discipline, consistent routine, nap and bedtime, limit but enforce rules, praise toddler, distraction as discipline family meals, self-feeding, drink form cup, food variety, limit bottle, limit sugar, brush teeth, first dental exam

FOLLOW UP:

15 months of age, sooner if concerns arise

Result - Copy and paste this output: