Child Medical Examination Record Case Study

Subjective

• Patient: 5 years old male Buddy;
• Chief complaint: Kindergarten well-child evaluation;
• History of present illness: Buddy is going to join kindergarten and goes through the required well-child evaluation. The boy is active, engaged in activities, and has friends at his preschool. He does not have any issues with sleeping, loves to play, and eats well. His bowel movements are soft and daily.
• Past medical history: Buddy has never been hospitalized, and the last physical was about two years ago. The only past medical problem mentioned is the one ear infection the boy had three years ago. He also has usual seasonal colds and stomach bugs; his mom denies broken bones or significant injuries. There were no surgeries, yet Buddy receives dental cleaning twice a year and fluoride treatments. The pregnancy was smooth, and he was born after 40 weeks without any difficulties. Buddy does not have any allergies, and his overall health is good, according to the development landmarks. His family moved to another place, and the boy missed some immunizations.
• Medications: The boy gets no daily medications, except for gummy multivitamins;
• Review of systems: Buddy is an easy-going, active 5-year-old boy. His mental conditions are good, speaking skills and understanding are at the appropriate level.
• Social history: Buddy lives with his two moms, who recently moved from New York and plan to get married soon. His mom denies any problems at home or in the relationship; there is no pressure on the non-traditional type of Buddy’s family. The witness states that they always wear belts and bike helmets, there are no guns at their home, and no one smokes around the boy. Although he does not do a particular sport, he is very active at home and preschool. Buddy is talkative, and he confirmed the information about belts, helmets, and his activity. There are no dietary issues; the boy has a balanced diet; he identifies himself as a boy. No particular diseases occurred in family history: his birth father is healthy, and the mother rarely has migraine headaches.

Objective

• Temp = 98.4
• Pulse = 80
• RR= 24
• Spo2 = 99%
• BP = 96/66
• Height 3’7
• Weight 40lbs
• BMI 15.2
• Mental status = A&O x3.
• General Appearance: 5 years old male, NAD, sits with his mom and does not look shy or scared. The skin is clear from lesions or eczema, with no bruising or other signs of trauma. The eyes are normal, with no strabismus, and visual acuity is 20/20 bilaterally. Ears are clean, intact, and tympanic membranes are normal, hearing test results – grossly normal hearing bilaterally. He does not have any dental issues and no tonsillar hypertrophy. The thyroid fits the limits for size and consistency; no cervical lymphadenopathy or masses detected. His lungs and cardio systems are normal, the abdomen is lean, and has no herniation, hepatosplenomegaly, tenderness, or mass. Male development is according to the age: tanner stage 1, bilaterally descended testicles, normal to palpation, circumcised male external genitalia, has no discharge or inflammatory signs. Neurological system and reflexes are within the norms: Brachial pulse = 2+, Triceps = 2+, Biceps = 2+, Brachioradialis = 2+, Knee/patella = 2+, Ankle/Achilles = 2+.

Assessment

Buddy is a healthy 5-year-old male from the two mothers’ family and has the well-check before the kindergarten enrolment. He missed the 4-year immunization, yet his overall health is appropriate, and the development meets the milestones. The absence of bad habits and illnesses in the family gives no reason to raise concerns.

Differential Diagnosis

No particular diagnosis was discovered during child evaluation.

Plan

1. The boy’s health conditions are good; he meets all physical and developmental milestones;
2. Immunizations to make based on Buddy’s record. Schedule the MMR, VAR, DTAP, and IPV vaccines according to the age requirements;
3. Patient Education: pay attention to the boy’s conditions during the post-vaccination period, educate the parents about possible symptoms of adverse reactions;
4. If Buddy has uncommon concerns or pains which appear continuously, it is required to visit a doctor or call the emergency.