Well Child Check Samples

Fun, Joy                                           DATE OF SERVICE 07/19/09

DOB:  05/19/95

4-Year Health Maintenance Exam.

Height: 38-1/2"Weight: 30 lb. BP: 88/60

Temp: 97.4° Pulse: 100Resp: 16

FAMILY HISTORY: Refer to Family History Sheet.

SOCIAL HISTORY: Refer to Historical Data Sheet.

PARENT CONCERNS/ HPI: Tonsils were quite enlarged and had been going on for one week.  The patient had a lot of drainage, sounded congested, and was snoring.  She was seen by Dr. Mackrell and a rapid strep was negative.  She did have a mild sore throat at that time.  It is better.  She has been eating okay.  No known allergy symptoms. 

INTERVAL HISTORY:

ROS: No concerns about eyes, ears, heart, lungs, gastrointestinal, genitourinary, skin, or musculoskeletal

systems.

No neurologic or developmental concerns.  No behavioral concerns.  Eats well.  Sleeps well.

All other systems are negative.

Allergies: None.

Illnesses: None.  The patient does have a history of recurrent urinary tract infections; her last one being

in 2/99.  She was seen by the urology, Dr. Rosenberg, had a voiding cystourethrogram and a renal

ultrasound which were both normal.  He recommended a trial of prophylactic antibiotics, and the mother

declined. 

Injuries or Accidents: None.

Medications: None.

The patient is eating pretty good these days.  Sleeps well.  Bedtime is about 9:00 p.m.  Stooling and

voiding without concerns.  The child is occasionally wet at night if she drinks a lot of fluids. 

GROWTH AND DEVELOPMENT: Speech and language skills are continuing to progress.  The patient is now interested in counting to 10.  Patient knows ABCs and is able to sing the ABC song.  Colors are recognized.  She is able to dress herself independently.

PHYSICAL EXAM: The patient is alert, active, and cooperative.  Head is normocephalic.  Pupils are equal and reactive to light.  Light reflex is symmetrical in both eyes.  Extraocular movements are normal, conjunctivae and eyelids appear normal.  Tympanic membranes are clear with normal landmarks and no fluid or infection.  Nose is clear with midline septum.  Tonsils are large.  They are not red.  There is no purulent matter, and they do not close to the midline.  Throat and mouth are normal with no erythema or exudate.  Neck is supple and symmetric.  There are no significant lymph nodes in neck or groin.  Cardiac exam reveals are regular rate with no murmurs or extra sounds.  Femoral pulses are normal.  Lungs are clear to auscultation with no rales or wheezes heard and no respiratory distress.  Abdomen is soft and non-tender.  There are no masses or organomegaly.  Normal bowel sounds are present.  The abdomen is nondistended.  Skin is clear to inspection and palpation without significant rashes.  External genitalia are normal.  No hernias detected.  Hip exam reveals hips to have full range of motion with no subluxation or dislocation detected.  Bones and joints all appear normal and non-tender, with full range of motion on all four extremities.  No evidence of scoliosis.  Neuromuscular exam is normal with normal reflexes.

A: 1. 4-year-old health maintenance exam, normal growth and development.

2. History of recurrent urinary tract infections, none recently.