WC – Yr 2_5 | 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: weight concerns asthma 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 urinates in a potty or toilet toilet training in progress toilet training achieved age-appropriate development some milestones not achieved

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

DENTAL: discussed and/or handout provided, brushing teeth with help 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, playing pretend with toys or dolls playing with other people limiting screen time no concerns identified

LANGUAGE: discussed and/or handout provided, being understood by others puting 3 to 4 words together using pronouns correctly pointing to body parts knowing animal sounds knowing at least one color no concerns identified

GROSS MOTOR: discussed and/or handout provided, puting on clothes with help jumping up and down walking up steps using one foot then the other running without falling catching large ball no concerns identified

FINE MOTOR: discussed and/or handout provided, poking food with fork washing hands grasping crayon with thumb and fingers no concerns identified

SAFETY: discussed and/or handout provided, choking prevention home safety: window falls, burns, pets, guns 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: grossly intact, 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 pupils equal round reactive to light 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 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_5

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