Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Well-Child Check - 7
1-month-old for a healthy checkup - Well child check
(Medical Transcription Sample Report)
This is a 1-month-old who comes in for a healthy checkup. Mom says things are gone very well. He is kind of acting like he has got a little bit of sore throat but no fevers. He is still eating well. He is up to 4 ounces every feeding. He has not been spitting up. Voiding and stooling well.PAST MEDICAL HISTORY:
Reviewed, very healthy.CURRENT MEDICATIONS:
None.ALLERGIES TO MEDICINES:
His formula fed on Enfamil Lipil. Voiding and stooling well. Growth chart reviewed with Mom.DEVELOPMENTAL:
He is starting to track with his eyes. He is smiling a little bit, moving hands and feet symmetrically.PHYSICAL EXAMINATION:
In general well-developed, well-nourished male in no acute distress.
DERMATOLOGIC: Without rash or lesion.
HEENT: Head normocephalic and atraumatic. Anterior fontanel soft and flat. Eyes: Pupils equal, round and reactive to light. Extraocular movements intact. Red reflexes present bilaterally. Does appear to have conjugate gaze. Ears: Tympanic membranes are pink to gray, translucent, neutral position, normal light reflex and mobility. Nares are patent, pink mucosa, moist. Oropharynx clear with pink mucosa, normal moisture.
NECK: Supple without masses.
CHEST: Clear to auscultation and percussion with easy respirations and no accessory muscle use.
CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs, heaves or gallops.
ABDOMEN: Soft, nontender, nondistended without hepatosplenomegaly.
GU EXAM: Normal Tanner I male. Testes descended bilaterally. No hernias noted.
EXTREMITIES: Pink and warm. Moving all extremities well. No subluxation of the hips and leg creases appear symmetric.
NEUROLOGIC: Alert, otherwise nonfocal. 2+ deep tendon reflexes at the knees. Fixes and follows appropriately to both voice and face.ASSESSMENT:
Well child check.PLAN:
1. Diet, growth and safety discussed.
2. Immunizations discussed and updated with hepatitis B.
3. Return to clinic at two months of age. Call if problems.
consult - history and phy., 1-month-old, healthy checkup, enfamil lipil, growth chart, immunizations, healthy, child, atraumatic, reflexes, checkup,
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