Student Name: 

Course:

Patient Name: (Initials ONLY): J. S

Date: April 30, 2024

Time:

Ethnicity: Hispanic

Age: 3

Sex: F

SUBJECTIVE (must complete this section)

CC: Parental concern about child's recurring fevers.

HPI: J.S, Patient presented with intermittent fevers over the past week, highest recorded temperature was 102°F. No other associated symptoms noted. Parents administered acetaminophen for fever control.

Medications: Acetaminophen for fever

Previous Medical History: None

Developmental History: Developmentally appropriate for age

Allergies: None

Medication Intolerances: None

Chronic Illnesses/Major traumas: None

Immunizations: Up to date

Hospitalizations/Surgeries: None

Health Promotion/Health Maintenance: Routine pediatrician visits maintained.

Nutrition/Diet: Balanced diet reported by parents.

Exercise/Regimen: None

Tobacco/Alcohol/Vaping/Illicit Drug Use or Exposure: None

Safety Measures: Appropriate car seat use reported.

Screening exams: Routine pediatric visits

FAMILY HISTORY (must complete this section)

M: Healthy

MGM: Hypertension

MGF: None

 F: Healthy

 PGM: Diabetes

PGF: None

Social History: Lives with parents in a smoke-free environment.

REVIEW OF SYSTEMS (must complete this section)

General: No weight loss or fever reported

Cardiovascular: No palpitations or cyanosis

Skin: No rashes or lesions

Respiratory: No cough or shortness of breath

Eyes: No redness, discharge, or visual disturbances

Gastrointestinal: No vomiting, diarrhea, or constipation

Ears: No ear pain or discharge

Genitourinary/Gynecological: No urinary frequency, urgency, or dysuria

Nose/Mouth/Throat: No congestion, runny nose, or sore throat

Musculoskeletal: No joint pain or swelling

Breast: N/A

Neurological: No seizures, tremors, or abnormal movements

Heme/Lymph/Endo: No bruising or swelling of lymph nodes

Psychiatric: No mood disturbances or behavioral changes