iHuman Buddy Theodore 5 year old maleCC: Kindergarten well-child evaluationHistory questions• Chief complaint Sx/Sx Characteristics:- How can I help you today? – patient- How can I help you today? witness- How
...
iHuman Buddy Theodore 5 year old male
CC: Kindergarten well-child evaluation
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
•
[Show More]
.png)
