THE DOCTOR WANTS ME TO CHARGE FOR THE ROV AND FOR AN SOV. I DON'T THINK THERE IS ENOUGH IN THIS NOTE TO DO THAT. WOULD LIKE ANOTHER OPINION PLEASE.
Reason for Visit/ Chief Complaint
16 yr rov.
chaperone declined.
Accompanied by Parents
Parental concerns? Y
behavorial issues- ODD. doesn't take responsibility for anything per mom. p's have thrown him out of the house for his behavior and arguing. fa thinks he is much better when he is on the meds.
not taking concerta- refuses.p's having difficulty coping with him.
drinking and urinating a lot in past year- gets worse.
Vital Signs
AGE 16y6.7m
BLOOD PRESSURE 114/68 R Arm
BLOOD PRESSURE (%) 29/51
HEIGHT 72.75 in
HEIGHT (%) 92
WEIGHT 171.2 lb
WEIGHT (%) 87
BMI 22.8
BMI (%) 72
Interval History
Illness/Injury since last vist? N
Specialty appointment since last visit? N
Hospitalization, Sugery, ER, Urgent visit since last visit? N
Family History
Family consists of: Mother; Father; Siblings
bro and sister
Infectious Diseases Y
legionnaires disease at 52. died of lung disease at 81. mgf
Asthma N
Deafness N
Eye N
Cardiac Y
mgf- valve replacement.
GI N
GU N
Endocrine Y
pgm,mgf-dm
Psychiatric N
Mental Retardation/ Developmental Delay N
Neurological Y
mgm-stroke- died of stroke at 72.
JRA Y
mom RA, pgf also
Skin N
Congenital N
Cancer N
Allergies N
Other Y
pgf-copd
Social History
Household changes?
moved in billerica. may 09.
Smokers in environment? Y
fa
Pets in environment? Y
2 dogs
Firearms in environment? Y
fa goes to gun range.locked
TB Risk Status? Low
Violence in home? N
Financial instability? N
Education Attends school; Has career plans
mechanic
Substances
Use tobacco? Current
5 / day
Use alcohol? Current
occ beer few few times a month.
Use drugs? Current
blunt mj weekends.
Sexual History
Age first sexual activity
16
Lifetime number of sexual partners
1
Partners opposite sex? Y
Partners same sex? N
Contraception used? Y
condoms
STDs? No
Education and Activities
Grade Level 11th Grade
School Type Public
Name of School
billerica hs.
School Performance Fair
Weaknesses
chemistry- failed
refused summer school.
Sports Yes
baseball- town league
Music Yes
guitar, bass.
Dance No
Clubs No
Drama No
Hobbies Yes
bikes
Diet
Rate eating habits Poor
Food groups? Meats; Vegetables; Fruits; Grains; Dairy
Other liquids? Milk; Juice; Water; Soda
discussed.
Comments
junk food
Sleep
Sleeps through night? Y
Sleep concerns? N
Safety
The following safety items were discussed (age approp.): helmet for bicycle-rollerblades-skiing; seat belts; driving
Physical Exam
General Appearance
WDWN, NAD
Skin
No cyanosis, rash, abnl pigmented lesions, striae, intertrigo, hirsutism
Head
Normocephalic, atraumatic, no facial dysmorphism
Eyes
PERRL, red reflex present, EOM normal, corneal light reflex normal
Ears
NL canals, TMs clear with normal landmarks
Nose
NL shape, no discharge
Mouth
NL tongue, mucosa, dentition
Throat
NL tonsils. No petechiae, exudate
Neck
Supple, no adenopathy or masses, no thyromegaly
Heart
RRR, no murmur, S1 & S2
Lungs
Clear to auscultation, no rales or wheezes
Abdomen
Soft, non-tender, no masses. Liver/spleen not enlarged. NL bowel sounds.
External Genitalia
NL external genitalia. No hernia. No discharge
Breast
No masses or discharge bilaterally
Extremity
No deformity with full range of motion, no poly/syndactyly, no edema, no genu varum/valgus
Neurological
Age appropriate reflexes present. DTRs symmetric/non focal
Gait
NL gait, without limp, in-toeing
Back
Flexible without scoliosis
Assessment Routine well child care EXCEPT:
adhd,behavioral problems. ODD.
polydipsia, polyuria
crafft=u-2
Plan
Plan
u/a and ua for chlam and gc
blood sugar.
MH list given= recommended family therapy.
discussed with p's and pt
Discussed diet, activity, screen time and counselled about weight management. 5/2/1/0.
recommended going back on the concerta- he thinks he will take it again.will decide soon.
Next appointment
1 y
if starts concerta will rto for f/u as usual.
Allergies
NKA
I THOUGHT WE COULDN'T USE PARTS OF THE ROV AS PART OF THE SOV SINCE THAT WOULD BE DOUBLE-DIPPING. ANY THOUGHTS?? THANKS
Reason for Visit/ Chief Complaint
16 yr rov.
chaperone declined.
Accompanied by Parents
Parental concerns? Y
behavorial issues- ODD. doesn't take responsibility for anything per mom. p's have thrown him out of the house for his behavior and arguing. fa thinks he is much better when he is on the meds.
not taking concerta- refuses.p's having difficulty coping with him.
drinking and urinating a lot in past year- gets worse.
Vital Signs
AGE 16y6.7m
BLOOD PRESSURE 114/68 R Arm
BLOOD PRESSURE (%) 29/51
HEIGHT 72.75 in
HEIGHT (%) 92
WEIGHT 171.2 lb
WEIGHT (%) 87
BMI 22.8
BMI (%) 72
Interval History
Illness/Injury since last vist? N
Specialty appointment since last visit? N
Hospitalization, Sugery, ER, Urgent visit since last visit? N
Family History
Family consists of: Mother; Father; Siblings
bro and sister
Infectious Diseases Y
legionnaires disease at 52. died of lung disease at 81. mgf
Asthma N
Deafness N
Eye N
Cardiac Y
mgf- valve replacement.
GI N
GU N
Endocrine Y
pgm,mgf-dm
Psychiatric N
Mental Retardation/ Developmental Delay N
Neurological Y
mgm-stroke- died of stroke at 72.
JRA Y
mom RA, pgf also
Skin N
Congenital N
Cancer N
Allergies N
Other Y
pgf-copd
Social History
Household changes?
moved in billerica. may 09.
Smokers in environment? Y
fa
Pets in environment? Y
2 dogs
Firearms in environment? Y
fa goes to gun range.locked
TB Risk Status? Low
Violence in home? N
Financial instability? N
Education Attends school; Has career plans
mechanic
Substances
Use tobacco? Current
5 / day
Use alcohol? Current
occ beer few few times a month.
Use drugs? Current
blunt mj weekends.
Sexual History
Age first sexual activity
16
Lifetime number of sexual partners
1
Partners opposite sex? Y
Partners same sex? N
Contraception used? Y
condoms
STDs? No
Education and Activities
Grade Level 11th Grade
School Type Public
Name of School
billerica hs.
School Performance Fair
Weaknesses
chemistry- failed
refused summer school.
Sports Yes
baseball- town league
Music Yes
guitar, bass.
Dance No
Clubs No
Drama No
Hobbies Yes
bikes
Diet
Rate eating habits Poor
Food groups? Meats; Vegetables; Fruits; Grains; Dairy
Other liquids? Milk; Juice; Water; Soda
discussed.
Comments
junk food
Sleep
Sleeps through night? Y
Sleep concerns? N
Safety
The following safety items were discussed (age approp.): helmet for bicycle-rollerblades-skiing; seat belts; driving
Physical Exam
General Appearance
WDWN, NAD
Skin
No cyanosis, rash, abnl pigmented lesions, striae, intertrigo, hirsutism
Head
Normocephalic, atraumatic, no facial dysmorphism
Eyes
PERRL, red reflex present, EOM normal, corneal light reflex normal
Ears
NL canals, TMs clear with normal landmarks
Nose
NL shape, no discharge
Mouth
NL tongue, mucosa, dentition
Throat
NL tonsils. No petechiae, exudate
Neck
Supple, no adenopathy or masses, no thyromegaly
Heart
RRR, no murmur, S1 & S2
Lungs
Clear to auscultation, no rales or wheezes
Abdomen
Soft, non-tender, no masses. Liver/spleen not enlarged. NL bowel sounds.
External Genitalia
NL external genitalia. No hernia. No discharge
Breast
No masses or discharge bilaterally
Extremity
No deformity with full range of motion, no poly/syndactyly, no edema, no genu varum/valgus
Neurological
Age appropriate reflexes present. DTRs symmetric/non focal
Gait
NL gait, without limp, in-toeing
Back
Flexible without scoliosis
Assessment Routine well child care EXCEPT:
adhd,behavioral problems. ODD.
polydipsia, polyuria
crafft=u-2
Plan
Plan
u/a and ua for chlam and gc
blood sugar.
MH list given= recommended family therapy.
discussed with p's and pt
Discussed diet, activity, screen time and counselled about weight management. 5/2/1/0.
recommended going back on the concerta- he thinks he will take it again.will decide soon.
Next appointment
1 y
if starts concerta will rto for f/u as usual.
Allergies
NKA
I THOUGHT WE COULDN'T USE PARTS OF THE ROV AS PART OF THE SOV SINCE THAT WOULD BE DOUBLE-DIPPING. ANY THOUGHTS?? THANKS
