WC – Yr 2 | CLINIBORG

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new patient existing patient parent present sibling/another family member present social services/group home/foster family present chaperon/MA present during visit interpretation provided by family member/SO interpretation provided by MA

PMH/SPECIAL NEEDS/PARENTAL CONCERNS: poor weight gain allergies anemia none identified

INTERVAL HISTORY: sick contact travel ER/UC visit illness injury hospitalization/surgery/procedure diagnostic/laboratory studies specialty consults new/changed medications ABX use no changes since last visit

MEDICATIONS: Rx OTC taking as prescribed not taking as prescribed none reported

SCREENING: lead TB completed today & discussed with parent consider formal referral negative deferred

GROWTH & DEVELOPMENT: normal interval growth in height and weight normal weight-for-length expressing feelings self-quieting toilet training when ready using correct terms for body parts providing praise helping with fears and nightmares age-appropriate development some milestones not achieved

NUTRITION: discussed and/or handout provided, no forced foods family meals food variety: adequate daily intake of fruits, vegetables, calcium-containing foods, iron-containing foods limiting juice/soda milk less 16 oz no concerns identified

DENTAL: discussed and/or handout provided, brushing teeth no concerns identified

FAMILY: discussed and/or handout provided, one-parent two-parent siblings good sibling relationships adequate living situation attends daycare stays at home housing problems custody issues social services no interval changes no concerns identified

BEHAVIOR & SOCIAL: discussed and/or handout provided, listening & responding to child playing along other children playing pretend games imitating adults providing adequate play time limiting screen time no concerns identified

LANGUAGE: discussed and/or handout provided, modeling appropriate language naming pictures using 20 words following 2-step command putting two words together no concerns identified

GROSS MOTOR: discussed and/or handout provided, kicking ball walking up/down stairs one step at a time throwing ball overhead jumping up/down no concerns identified

FINE MOTOR: discussed and/or handout provided, turning book pages one at a time stacking blocks no concerns identified

SAFETY: discussed and/or handout provided, choking prevention home safety: window falls, burns, pets, guns playground safety, supervision outside car safety water safety smoking household firearms in home no concerns identified

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ROS
10-point review of systems was performed and results were negative except for any positive results below
General:

HEENT:

Chest/Respiratory:

GI:

GU:

MSK:

Neurologic:

Psychiatric:

Dermatologic:

Hematologic/lymphatic:

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VACCINATION: UTD missing shots administered today deferred declined

OFFICE DIAGNOSTICS: H&H UA normal non-specific changes abnormal discussed with parent none performed today

Appearance: well-appearing active interactive crying consolable NWOB moist mucous membranes age-appropriate behavior inconsolable irritable uncooperative with exam

Skin: pink, no rashes warm and well perfused no bruising

Head/Face: normocephalic and atraumatic symmetrical face scalp tenderness plagiocephaly swelling

Eyes: red reﬂex present bilaterally fixes and follows normal ocular alignment clear conjunctiva w/o exudates or hemorrhage conjunctival injection epiphora conjunctival exudate allergic shiners dysconjugate gaze

ENT: normal ear canals & TMs, normal external nose normal dentition for age no oral lesions op w/o swelling or exudates

Neck: symmetric with free painless ROM and no masses supple no LAD anterior LAD posterior LAD

Chest/Lungs: unlabored respirations, symmetrical chest expansion clear and equal breath sounds bilaterally decreased bilaterally wheezing

CV: regular rhythm no murmurs tachycardia irregular heart rhythm systolic murmur

Abdomen: no distension normal active bowel sounds soft non-tender no obvious palpable masses umbilical hernia

GU: declined exam normal external genitalia testes down bilaterally uncircumcised circumcised

MSK: no gross deformities ambulates w/o limp or alteration in gait normal spine strength, tone, & bulk symmetrical

Neuro: social appropriate for age speech

A/P:
well child

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ORDERS - RX: OTC electronic paper given to MA to be transmitted to pharmacy none

ORDERS - LABS: CBC CMP TSH Lipids A1C lead UA none

ORDERS - REFERRALS: early intervention WIC none

ORDERS - FORMS/RELEASE/CLEARANCE: daycare physical none

INSTRUCTED ON: milestones, wellness, screening findings, exam findings, appropriate follow up POC, reporting medication side effects immediately, indications for immediate direct evaluation and/or contacting emergency services

PLAN OF CARE: verbalized understanding of & agreement with POC did not agree with my POC – will seek second opinion/further care elsewhere

FOLLOW UP: 6 months, sooner if concerns arise, RTC 24 hours RTC 2-3 days RTC 1-2 weeks RTC 3-4 weeks

PARENTAL BEHAVIOR: calm respectful anxious suspicious irritable frustrated forceful insisting on particular medication, test, referral, or accommodation argumentative hostile raising voice agitated previous providers/staff criticisms verbal threats withdrawn hypoverbal

BARRIERS TO CARE: social/financial problems incomplete history d/t parental lack of knowledge/affect incomplete history d/t language barrier vague shifting complaints history not supported by objective findings supporting documentation unavailable poor cooperation with exam poor compliance with POC intolerance of/therapeutic failure on multiple meds lack of motivation negative attitude to diagnostic impression & proposed tx none identified

WC – Yr 2

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