.C. 5-year-old well child visit

NU632 Unit 3 Discussion Case

HPI: M.M. is a 5 y.o. F who present to HU clinic with her father for her 5-year-old well child visit. She reports liking school and has made some friends. Her favorite part of the school day is “PE.” At present time she reports no complaints. Father reports no concerns with development, behavior or nutrition.

PMH: Born at 39 weeks’ gestation via cesarean section for being in a breech position. There were no complications at birth. There were no complications throughout the pregnancy. The infant’s mother denies tobacco use, drug use, or alcohol use during pregnancy. The infant was breastfed. Allergies: No known drug allergies

Medications: Disney Princess Gummy Vitamin

Social History: The child lives with her mother and father who have been married for 2 years. Both parents work full-time. She started public school two months ago which is full day kindergarten. Father vapes in the home. Both parents report social drinkers on the weekend, “couple of beers with dinner.” There are no firearms in the house.

Family History: Mother and father deny any significant medical history.

Health Maintenance/Promotion:

Review of Systems

General: Denies any concerns, unexplained fevers, or growth and developmental concerns. Skin: Denies any rash, lesions, or concerns with eczema.

Head: Denies headache, trauma or falls.

ENT: Denies any concerns with ears, nose, or throat.

Neck: Denies pain with ROM neck. Denies masses or lumps.

CV: Denies any chest pain, cyanosis, heart racing or sweating.

Lungs: Denies any cough, congestion, wheezing, or difficulty breathing.

GI: Denies food intolerances. Denies weight loss, nausea, vomiting, constipation or diarrhea. GU: Negative for burning or blood in urine. Musculoskeletal: Denies pain, trauma, numbness.

Neurological: denies changes in senses. Psych: Denies difficulty concentrating, tearful episodes, anxiety or seclusion. Endocrine: Denies increase thirst or urination. Hematologic: Denies bruising or bleeding.

Objective

VS: Temperature: 98.1 F, 107/62, HR: 66, RR: 20, 100% on RA, Ht: 55 in (93.52%), Wt.: 97 lbs. (98.3%),

BMI: 22.54 (97%).

General: Well developed, well-nourished and hydrated, no apparent distress. Appropriate dressed. Skin: No evidence of rash or lesions.

Head: Normocephalic.

Eyes: The lids and conjunctiva are normal. Pupils are irises are normal fundoscopic exam reveals red reflex present bilaterally.

ENT: Normal external ears and nose. Normal external auditory canals and tympanic membranes. Hearing is grossly normal. Dental caries on B, C, M, L. Oropharynx: normal mucosa, palate, and posterior pharynx.

Neck: Supple and no lymphadenopathy.

CV: Normal rate and rhythm. Normal S1 and S2 heart sounds heard on auscultation with no S3 or S4. No murmurs. Femoral pulse 2+ bilaterally.

Lungs: Normal respiratory rate and pattern with no apparent distress. Bilateral breath sounds clear on auscultation without rales, rhonchi, or wheezes.

Abd: Normal bowel sounds. No masses or tenderness or organomegaly observed.

GU: Normal female genitalia. Tanner stage 1.

MSK: Grossly normal tone and muscle strength. Normal range of motion in extremities.