Patient Name: (Initials ONLY): J. S
Date: April 30, 2024
Time:
Ethnicity: Hispanic
Age: 3
Sex: F
SUBJECTIVE (must complete this section)
CC: Parental concern about child’s recurring fevers.
HPI: J.S, Patient presented with intermittent fevers over the past week, highest recorded temperature was 102°F. No other associated symptoms noted. Parents administered acetaminophen for fever control.
Medications: Acetaminophen for fever
Previous Medical History: None
Developmental History: Developmentally appropriate for age
Allergies: None
Medication Intolerances: None
Chronic Illnesses/Major traumas: None
Immunizations: Up to date
Hospitalizations/Surgeries: None
Health Promotion/Health Maintenance: Routine pediatrician visits maintained.
Nutrition/Diet: Balanced diet reported by parents.
Exercise/Regimen: None
Tobacco/Alcohol/Vaping/Illicit Drug Use or Exposure: None
Safety Measures: Appropriate car seat use reported.
Screening exams: Routine pediatric visits
FAMILY HISTORY (must complete this section)
M: Healthy
MGM: Hypertension
MGF: None
F: Healthy
PGM: Diabetes
PGF: None
Social History: Lives with parents in a smoke-free environment.
REVIEW OF SYSTEMS (must complete this section)
General: No weight loss or fever reported
Cardiovascular: No palpitations or cyanosis
Skin: No rashes or lesions
Respiratory: No cough or shortness of breath
Eyes: No redness, discharge, or visual disturbances
Gastrointestinal: No vomiting, diarrhea, or constipation
Ears: No ear pain or discharge
Genitourinary/Gynecological: No urinary frequency, urgency, or dysuria
Nose/Mouth/Throat: No congestion, runny nose, or sore throat
Musculoskeletal: No joint pain or swelling
Breast: N/A
Neurological: No seizures, tremors, or abnormal movements
Heme/Lymph/Endo: No bruising or swelling of lymph nodes
Psychiatric: No mood disturbances or behavioral changes
OBJECTIVE (Document PERTINENT systems only, Minimum 3)
Weight: 15kg
Height: 95cm
BMI: 16.6
BP: 120/80 mmHg
Temp: 37°C
Pulse: 100 bpm
Resp: 20 bpm
SPO2%:93%
General Appearance: Well-nourished, interactive child.
Skin: No rashes or lesions
HEENT: Head: Normocephalic, atraumatic; Eyes: Pupils equal, round, reactive to light; no discharge or redness; Ears: Tympanic membranes intact bilaterally; Nose: Nasal mucosa pink, no discharge
Throat: Oropharynx pink, moist
Cardiovascular: Heart sounds regular, no murmurs
Respiratory: Respiratory rate within normal limits, lungs clear to auscultation bilaterally
Gastrointestinal: Abdomen soft, non-tender, no masses or organomegaly
Breast: N/A
Genitourinary: Diaper dry, no signs of urinary tract abnormalities
Musculoskeletal: Extremities symmetric, full range of motion
Neurological: Alert and responsive, normal tone and reflexes
Psychiatric: Not applicable
Diagnostic Studies: None
Special Tests: None