Daniel DeMarco Focused H&P#4 Pediatrics

Chief Complaint: Here today for Annual Physical

 

History of Present Illness:

 

AV is a 15yo male with PMH depression for which he speaks to his school counselor here today for annual physical. No interval history. Reports his diet has “not been the best,” eating only one or two meals per day (school lunch and McDonald’s after school) and drinking juice and three glasses of soda per day. Having one soft, nonbloody BM per day and voiding q3h without hematuria or dysuria. Reports that he sleeps only 3-4h every night as he uses his phone in bed and he shares a room with his brother who snores. AV states he often “naps in class.” He is in 8th grade and states that he is failing at least 3 of his classes and is required to make up work. Mother states that after school he often “stays out until 6PM” and that she doesn’t
“know where he is or what he is doing.” Last dental exam approximately 1 year ago at which time he received fillings for several cavities. Last eye exam in March at which time his prescription increased in strength.

 

Immunizations: UTD

Allergies: NKDA

Medications: Denies

PMH: Depression

PSH: Denies

Social History

Home: Lives with mother, father, and three siblings at home. Older sister with MRCP. Mother and father are nonsmokers.

Education and Employment: In 8th grade at public school. Failing several classes. Has plans to go to high school. Wishes to get his working papers.

Activities: Enjoys playing soccer with friends.

Drugs: History of e-cigarette use x 1 year. Quit last month. Denies EtOH use, tobacco use, marijuana use, other illicit drug use.

Sexuality: Identifies as male. Currently in relationship with female partner. Not sexually active.

Family History: Denies

 

Review of Systems:

General: Denies fever, anorexia, weight loss, weight gain, change in activity level 

Neuro: Denies HA, trauma, LOC, seizure activity, developmental delays 

HEENT: Denies change in vision, hearing, pruritus, photo/phonophobia, neck pain, runny nose, ear pain, sore throat

CV: Denies shortness of breath, sweating, color changes with feeding, chest pain, palpitations, recent history of murmur, fainting, or dizziness with activity 

Respiratory: Denies cough, wheezing, shortness of breath

GI: Denies nausea, vomiting (bloody/bilious), diarrhea, constipation, hematemesis, hematochezia, or melena; describe stooling habits 

GU: Denies dysuria, frequency, urgency, hematuria

Endo: Denies polyuria/polydipsia, heat/cold intolerance, growth pattern abnormalities

MS: Denies myalgias, arthralgias, trauma, limp, weakness

Skin: Denies rashes, bruising, petechiae

Psychiatric: Admits feelings of sadness. Denies HI/SI.

 

Physical Exam:

Vital Signs:

BP: 110/74

Pulse: 70bpm

RR: 14 breaths/min

Temp: 36.2C

SpO2: 100%RA

Ht: 67.0 inches

Wt: 60 kg

 

General Survey: Alert, NAD. Using cellular phone.

Skin: No petechiae, masses, lesions. No jaundice, cyanosis, mottling. No rashes.

Hair: Average quantity and distribution.

Nails: Capillary refill <2s throughout.

Head: NC/AT. Non-tender to palpation throughout.

Eyes: PERRLA. EOM intact and nonpainful. Red reflex present bilaterally. No crusting on lashes. No discharge.

Ears: External ear with no masses, lesions. Nontender to palpation. Auditory canal with no injection. B/L TMs pearly gray with cone of light in appropriate position.

Nose: Nares patent. Mucosa pink. Septum midline. Turbinates non-boggy, non-hyperemic.

Throat: Good dentition. Gingiva without lesions, masses. Uvula midline. No tonsillar swelling. 

Neck: Supple. No thyromegaly. No lymphadenopathy.

Cardiovascular: Regular rate and rhythm. S1 and S2. No murmurs, gallops, rubs.

Chest and Pulmonary: Symmetrical rise and fall of chest wall. No labored breathing, accessory muscle use. Clear to auscultation bilaterally.

Abdomen: Nondistended. BS +. Soft, non-tender. No guarding, rebound tenderness. No hepatosplenomegaly.

 

Assessment/Plan:

AV is a 15yo male with PMH depression here for annual physical.

 

#Depression

– Referral for Psychologist and Psychiatrist given

 

Follow-Up: Return to clinic in 1 year for annual physical or sooner prn

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student