CHIEF COMPLAINT
5-year-old well child check
HISTORY OF PRESENT ILLNESS
Patient is a 5-year-old female here for a routine well child visit accompanied by her mother. She has a history of asthma, which is well-controlled with current medication.
Parental Concerns: Mother expressed concern about the child's picky eating habits and occasional nightmares. She also mentioned that the child has been more irritable lately.
Nutrition/Elimination: The child has a limited diet, preferring only certain foods, and has regular bowel movements.
Dental: No dental issues reported, regular dental check-ups are maintained.
Sleep: Sleeps in her own bed, but experiences occasional nightmares.
Menstrual status: Not applicable.
Development/Behavior: SWYC Developmental screening tool used, score within normal limits. No developmental concerns noted.
Safety: Car seat used appropriately. Home safety measures in place.
Health Risks: No exposure to second-hand smoke. No anxiety or depression noted.
Childcare/School: Attends kindergarten, no issues reported.
Additional Concerns: None reported.
REVIEW OF SYMPTOMS
All other systems negative except as documented in the HPI.
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PHYSICAL ASSESSMENT
GENERAL - Well-nourished, active child.
HEAD – Normocephalic, atraumatic.
EYES - Conjunctiva and lids clear, pupils equal, round, reactive to light and accommodation, corneal light reflex normal.
EARS, NOSE, MOUTH AND THROAT - Ears and nose normal on external inspection, tympanic membranes intact, oropharynx clear.
NECK - Supple, no lymphadenopathy.
PULMONARY - Normal respiratory effort, clear to auscultation bilaterally.
CARDIOVASCULAR - Regular rate and rhythm, no murmurs.
ABDOMEN - Soft, non-tender, normal bowel sounds, no hepatosplenomegaly.
LYMPHATIC - No cervical or supraclavicular lymphadenopathy.
MUSCULOSKELETAL - Normal muscle tone and strength.
SKIN - No rashes or lesions.
NEUROLOGIC - Alert, oriented, normal sensation and mental status.
GENITOURINARY - Normal external genitalia.
ASSESSMENT
1. 5-year-old well child check
2. Asthma, well-controlled
PLAN/RECOMMENDATIONS
1. Next well visit at 6 years of age.
2. Immunizations: Discussed required vaccines as indicated by the CDC immunization schedule. Immunizations given today as above after informed consent discussion during which all parent's questions were answered, concerns were reviewed at length, and I have personally provided face to face counseling on all vaccine components.
3. Advised on balanced diet to address picky eating habits.
4. Discussed sleep hygiene to help with nightmares.
Counseling: Discussed importance of balanced nutrition and regular physical activity.
Return to care instructions and parent understanding of plan documented.
