%PM, %941 %27 %2017 %14:%Jul

Well Child Check >12 year old

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SUBJECTIVE:

_ here for well child check. No parental or patient concerns at this time.

Here with parent: _

RISK ASSESSMENT (non-confidential):

- Has never fainted before.

- No h/o cough, chest pain, or shortness of breath with exercise.

- Has never had a significant head injury.

- No family history of sudden death while exercising.

- No family history of MI or stroke before age 55.

RISK ASSESSMENT (confidential):

- Home: Safe, peaceful home environment. Family members all get along, more or less.

- Education/Employment: School is going _. No problems with safety or bullying at school.

- Eating: No concerns about body appearance. Getting sufficient calcium in diet (at least 4 servings per day). No dietary restrictions.

- Activities: Enjoys hanging out with friends. Screen time _. Is involved in _

- Drugs: No history of tobacco, EtOH, or drug use. No friends are using these substances.

- Safety: No history of violent relationships at home or elsewhere.

- Sex: Prefers _. Has not been sexually active (oral or genital) yet.

- Suicidality/Mental Health: No concerns. No history of physical or sexual abuse. Sleeps well at night.

PM/SH:

Normal pregnancy and delivery. No surgeries, hospitalizations, or serious illnesses to date.

OB/GYN HX:

Menses started at age _, and is regular.

SOCIAL:

- No smokers in the home.

- No TB or lead risk factors.

- Plans after high school: _

IMMUNIZATIONS:

- Up to date.

OBJECTIVE:

- WEIGHT: BMI _ BMI _ %ile

- GEN: Normal general appearance. NAD.

- HEAD: NCAT.

- EYES: PERRL, red reflex present bilaterally. Light reflex symmetric. EOMI.

- ENMT: TMs and nares normal. MMM. Normal gums, mucosa, palate, OP. Good dentition.

- NECK: Supple, with no masses.

- CV: RRR, no m/r/g.

- LUNGS: CTAB, no w/r/c.

- ABD: Soft, NT/ND, NBS, no masses or organomegaly.

- GU: Normal genitalia, Tanner stage _

- SKIN: WWP. No skin rashes or abnormal lesions.

- MSK: No deformities or signs of scoliosis. Normal gait. No clubbing, cyanosis, or edema.

- NEURO: Normal muscle strength and tone. No focal deficits.

LABS/STUDIES:

- Urine dip normal.

- Hearing screen normal.

- Snellen testing: _

ASSESSMENT/PLAN:

* Healthy _ yo adolescent

- CBC ordered. No indication for DM screening.

- Check lipid panel 9-11 yo & 17 - 21 yo (universal rec)

- Check HIV 15-18 yo, repeat PRN thereafter

- Screen for depression yearly > 12 yo PHQ2: _

- Follow in one year, or sooner PRN.

- ER/return precautions discussed.

* Vaccines today:

- Influenza, HPV (0, 1-2, and 6 months, > 9 yo), Tdap (11-12), Meningococcal ACWY (11-12, boost 16 yo), Men B (16-23, or > 10 w/ incr risk)

* Anticipatory guidance (discussed or covered in a handout given to the family)

- Confidentiality of visit documentation.

- Puberty, sex, abstinence, safe dating.

- Avoiding tobacco, drugs, alcohol; and never getting into a car with someone under the influence.

- Dealing with stress.

- Discipline and role models.

- Seat belts, helmets and safety gear, sunscreen

- Internet safety, limiting screen time

- Importance of daily exercise.

- Obesity prevention and adequate calcium.

- Good dental hygiene.

- Eliminating guns from the home, or locking bullets separately

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