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
- venturafamilymed