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iHuman_Buddy_Theodore.pdf

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History questions • Chief complaint Sx/Sx Characteristics: - How can I help you today? – patient - How can I help you today? witness - How old are you? – patient - How is his overall health? – witness - Does he have any allergies? – witness - When was his last physical? – witness - Are his immunizations up to date? – witness - Any previous medical, surgical, or dental procedures? – witness - How is his appetite? Any recent change? – witness - Tell me about any current or past medical problems? – witness • Associated Sx/Sx Characteristics: - How many bowel movements does he have a day? – witness - Has there been a change in his urination frequency? – witness - How are his grades in school? – witness - Is he having any difficulty sleeping? - Witness • Risk factors – PMH: - Were there any complications with his birth? – witness - Has he ever been hospitalized? - witness - Is he taking any prescription medications? – witness - Is he taking any OTC or herbal medications? – witness - Are there any diseases that run in his family? – witness - Tell me about his diet, what he normally eats – witness - Tell me about daily exercise or sports that he plays – witness • Risk factors – FH: - Tell me about the health of his grandparents, parents, and children – witness - How is his family and family life? – witness• Risk factors – SH: - How does he identify himself in terms of gender? – witness - Do you always wear seatbelts? – patient - Does he always wear seatbelts? – witness - Do you wear a bike helmet when riding a bicycle or motorcycle? – patient - Does he wear a bike helmet when riding a bicycle or motor cycle? – witness - Tell me about daily exercise or sports that you play – patient - Is he exposed to second hand smoke? – witness - Are there any guns in his home? If so, are they stored in a secure location? – witness Physical Exam • Vitals: temp, pulse, BP • Skin, hair, nails: inspect skin overall • HEENT: inspect/palpate head, inspect eyes, test visual acuity, look into ears with otoscope, test hearing, inspect mouth/pharynx • Neck: palpate neck • Chest wall & lungs: auscultate lungs • Heart: auscultate heart • Abdomen: palpate abdomen • Neurological: gait and stance • Genitourinary: male exam Key findings/Problem statement • Missed scheduled immunizations at age 4 – MSAP (most significant active problem) • Healthy 5 year old child – related • Normal development to date – related • No significant PMH – related • Two-mother family – related • No worrisome genetic FH issues – related •

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