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