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Name: Jones, Joe ID: 0001 Sex: Male Age: 6 months, 5 days
SUBJECTIVE:
This six month old male infant presents for well-child examination. Infant lives with father, mother and
brother.
Review of Systems
Nutrition: Taking 6-8 oz of baby formula every 4 hours while awake. Solid foods eaten in form of baby
cereal, fruit and vegetables (20 36oz daily)
Developmental milestones: Razzing yes; Reaches for objects yes; Pulls to sit without head lag Yes,
not so with lag; Smiles spontaneously yes; Orients to bell yes; Babbling yes
OBJECTIVE:
Height: 27.1 inches Weight: 16.67 pounds. Well appearing infant in no distress
Eyes: visual acuity intact, conjunctiva clear sclera non-icteric EOM intact, Red light reflex bilaterally,
PERRL, fundi have normal optic discs and vessels, no exudates or hemorrhages, no evidence of
strabismus
Ears: EACs clear, TMs translucent and mobile, ossicles normal appearance, hearing intact
Heart: no cardiomegaly or thrills, regular rate and rhythm, no murmur or gallop, radio-femoral pulses
present and palpable simultaneously
Genitalia: circumcised penis, urethral meatus patent, no hypospadias, testes descended, no hernias, no
scrotal masses.
PLAN:
Due for 6 month shots: IPV, DTap, Hep B, PCV, HiB. Follow up at 12 months of age.
Parent Counseling Nutrition: Stressed importance of intake of iron-rich foods, avoidance of sweets.
Continue breast feeding/formula 16-20oz per day. Injury prevention: Discussed infant safety seat, smoke
detector, hot water heater temperature, electric outlet covers, stairway gates, window guards, storage
of drugs and toxic chemicals, poison control telephone number.
Codes:
E/M 99381 IMMUNIZATIONS 90645, 90645, 90460, 90670, 90713, 90700, 90461 x 4, 90744
Name: Jones, Joey ID: 0002 Sex: Male Age: 11 years, 1month
SUBJECTIVE:
Interim problems since last visit Patients blood sugars around 100, URI symptoms have improved,
Patient exercises often.
Review of Systems
Current Medications:
Social History:
Occupation student; Education in 6th grade; Nutrition eats healthy; Exercise wrestling and
basketball; Smoking no smoking or use of recreational drugs by any adults in/around the house
Nutrition:
Milk: 2% milk 16 oz/day; Diet habits: emphasizes fruits, vegetables, whole grains, lean meats, poultry,
fish, beans, eggs and nuts.
OBJECTIVE:
Height percentile: 71.78 Weight percentile: 95.47. Well appearing, well-nourished in no distress.
Oriented, normal mood and effect.
Ears: EACs clear, TMs translucent and mobile, ossicles normal appearance, hearing intact
Genitalia: penis w/o lesions, no inguinal hernias, tanner stage Extremities: no deformities, full range of
motion
ASSESSMENT:
PLAN: Schedule to see Endocrinologist for follow up on diabetes. Discussed diet and exercise with
patient and child and also discussed pubertal changes and sex education. Follow-up in 4 months.
Codes: