Safety Practices

Safety Practices

Name: M. O.

Date: 05/21/18

Sex: Male

Age/DOB/Place of Birth: 8 Y/O /04-20-2010/Miami, Florida

SUBJECTIVE

Historian: Dad

Present Concerns/CC:

“He hurt his right arm.”

Child Profile: (Sexual History (If appropriate); ADLs (age appropriate); Safety Practices; Changes in daycare/school/after-school care; Sports/physical activity; Developmental Hx)

Healthy, well-nourished child. Age appropriate communication and development. Patient is in the 2nd grade and doing well.

HPI: (must include all components)

8 year old male patient presenting with Dad with a complaint of injury to right arm. Dad states that patient fell today at school and landed on his right wrist. The patient reports that the extremity was iced at school. Dad denies administration of pain medication.

Medications: (List with reason for med )

None.

PMH:

Allergies: NKDA

Medication Intolerances: None

Chronic Illnesses/Major traumas: None

Hospitalizations/Surgeries: None

Immunizations: Updated

Family History ( Please identify all immediate family)

Father alive and well, mother alive and well.

Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status

He lives with both parents. Dad reports that he occasionally smokes cigars but not in the presence of patient. Patient is in the 2nd grade.

ROS

General

Denies, headache, chills, myalgia.

Cardiovascular

Denies chest pain/discomfort, heart problems

Skin

Denies rash or lesions.

Respiratory

Denies cough, difficulty breathing, wheezing.

Eyes

Denies discharge from eye, redness, or pain

Gastrointestinal

Denies abdominal pain, nausea, vomiting, change in appetite diarrhea, and constipation.

Ears

Denies pain or discharge

Genitourinary/Gynecological

Denies dysuria or changes in urinary pattern.

Nose/Mouth/Throat

Denies nasal congestion, nasal discharge or bleeding, mouth sores, mouth soreness, mouth pain, sore throat, or difficulty swallowing

Musculoskeletal

Reports injury and pain to le