儿科保健检查英文病历规范.docVIP

Chief Complaint (1/1): This 1 year -old female presents today for a health maintenance exam. Patient was accompanied by mother. The child eats 3 meals a day plus 2 snacks and is off the bottle. Gabriella sleeps through the night. Gabriella takes morning and afternoon naps. Mother is concerned about childs red, matted eye and not walking completely alone yet. Immunizations need to be updated at todays visit. Developmental milestones: 1 year developmental milestones reached: bangs blocks together, drinks from cup, eating finger foods, feeds self, gives toys on request, imitates vocalizations, looks for dropped or hidden objects, points to desired objects, pulls to stand and cruises, releases cube into cup after demonstration, says mama and dada with meaning, says one or two other words, tries to build tower of 2 cubes and waves bye. Allergies: No known medical allergies. Medications: None. PMH: Past medical history is unremarkable. PSH: No previous surgeries. Family History: Patient admits a family history of cancer associated with maternal aunt, hypertension associated with paternal grandfather. Social History: She lives at home with parents. Patient admits being in daycare. Review of Systems: No change since last visit Physical Exam: Temp: 97.6 Height: 0 ft. 31 in. Weight: 28 lbs. BMI: 20 Growth Chart Entry: Weight: 28 lbs 0 ozs Height: 0 ft 31 in Head Circumference: 18.50 in Patient is a 1 year-old female who appears in no apparent distress, well developed and well nourished. Inspection of head and face shows anterior fontanel normal, posterior fontanel normal and head is normocephalic and atraumatic. Eyes: Fundoscopic exam reveals red reflex is present bilaterally. Alignment is normal. Sclera is white bilaterally. Left inferior palpebral conjunctiva reveals conjunctivitis. Ocular motility exam reveals gross orthotropia with full ductions and versions bilateral. ENT: Pinn a: normal. Otoscopic examination reveals no abnormalities of external auditory canals