Shawn Henderson
History of Present Illness:
Reason for Encounter: Well Visit
HPI:
This patient is a 4 month old who presents for a wellness visit to the
primary care clinic with their mother, who is primary historian. The mother
reports no concerns, and her depression screening is negative.
General: Denies fever or weight loss
HEENT/Neck: Denies otorrhea, high-arched palate, or issues with
sucking/swallowing.
Cardiovascular: Denies murmurs or cyanosis.
Respiratory: Denies wheezing, accessory muscle usage.
Gastrointestinal: Denies abdominal distension or excess gas. Reports seedy,
yellow stools.
Genitourinary: denies hematuria, scrotal discoloration or foul smelling
urine.
Musculoskeletal/Osteopathic Structural Examination:
Denies limp with walk or limb length discrepancies.
Neurologic: Denies seizure or extremity weakness
Integumentary/Breast: denies petechiae, jaundice, lacerations, abrasions,
skin tags, or preauricular pits.
Hematologic/Lymphatic: Denies bleeding diatheses
PMX:
None
Prenatal History: mother received appropriate prenatal care with no issues
or concerns
, Birth history: born at 39 w 5 d to G2P2 mother via spontaneous vaginal
delivery without use of forceps or vaccum assistance.
Hosptial/Surgeries
None
Medications: Vitamin D 400IU PO daily
Allergies: NKDA
Preventive Health:
Routine well examinations: last checkup 1 month ago, received
erythromycin eye ointment and vitamin K at birth
Dental: Dental checkup scheduled in 4 months
Vision: due at 6 months
Immunizations:
Heptatitis B series: completed 1 of 3 dose series: at birth; next dose due
today
Diptheria, Tetanus, Pertussis (DTaP): Completed 0 of 5-dose series: first
dose due today.
Haemophilus influenzae type b (HIB) series: completed 0 of 4 dose series:
first dose due today
Poliovirus (IPV) series: completed 0 of 4 dose series: first dose due today.
Pneumococcal (PCV13 or PCV23): completed 0 of 4 dose-series: first dose
due today
Rotavirus (RV): compelted 0 of 3 dose series: first dose due today.
Measles, Mumps, Rubella (MMR) series: completed 0 of 2 dose series.
Varicella (VAR) series: completed 0 of 2 dose series
Hepatitis A (Hep A) series: completed 0 of 2 dose series
Influenza (IIV): completed 0 of 2 dose series
RSV: Mother received RSV vaccine before child’s birth. COVID-19: not
received.
History of Present Illness:
Reason for Encounter: Well Visit
HPI:
This patient is a 4 month old who presents for a wellness visit to the
primary care clinic with their mother, who is primary historian. The mother
reports no concerns, and her depression screening is negative.
General: Denies fever or weight loss
HEENT/Neck: Denies otorrhea, high-arched palate, or issues with
sucking/swallowing.
Cardiovascular: Denies murmurs or cyanosis.
Respiratory: Denies wheezing, accessory muscle usage.
Gastrointestinal: Denies abdominal distension or excess gas. Reports seedy,
yellow stools.
Genitourinary: denies hematuria, scrotal discoloration or foul smelling
urine.
Musculoskeletal/Osteopathic Structural Examination:
Denies limp with walk or limb length discrepancies.
Neurologic: Denies seizure or extremity weakness
Integumentary/Breast: denies petechiae, jaundice, lacerations, abrasions,
skin tags, or preauricular pits.
Hematologic/Lymphatic: Denies bleeding diatheses
PMX:
None
Prenatal History: mother received appropriate prenatal care with no issues
or concerns
, Birth history: born at 39 w 5 d to G2P2 mother via spontaneous vaginal
delivery without use of forceps or vaccum assistance.
Hosptial/Surgeries
None
Medications: Vitamin D 400IU PO daily
Allergies: NKDA
Preventive Health:
Routine well examinations: last checkup 1 month ago, received
erythromycin eye ointment and vitamin K at birth
Dental: Dental checkup scheduled in 4 months
Vision: due at 6 months
Immunizations:
Heptatitis B series: completed 1 of 3 dose series: at birth; next dose due
today
Diptheria, Tetanus, Pertussis (DTaP): Completed 0 of 5-dose series: first
dose due today.
Haemophilus influenzae type b (HIB) series: completed 0 of 4 dose series:
first dose due today
Poliovirus (IPV) series: completed 0 of 4 dose series: first dose due today.
Pneumococcal (PCV13 or PCV23): completed 0 of 4 dose-series: first dose
due today
Rotavirus (RV): compelted 0 of 3 dose series: first dose due today.
Measles, Mumps, Rubella (MMR) series: completed 0 of 2 dose series.
Varicella (VAR) series: completed 0 of 2 dose series
Hepatitis A (Hep A) series: completed 0 of 2 dose series
Influenza (IIV): completed 0 of 2 dose series
RSV: Mother received RSV vaccine before child’s birth. COVID-19: not
received.
