.6mwcc

6 Month Well Child Check

• Growing and developing normally
• Administered 6 month vaccines today. PCV 20, Vaxelis (DtaP, IPV, Hep B, Hib) and Rotavirus
• EDPS obtained today and negative
• Recommended influenza vaccine in the fall
• Follow up at 9 month well child check

.9mwcc

9 Month Well Child Check

• Growing and developing normally
• Up to date on routine vaccinations
• Follow up at 12 month well child check

.12mwcc

12 Month Well Child

• Growing and developing normally
• Vision screen normal
• Negative lead and TB screening questionnaires
• Hemoglobin obtained and normal for age
• Administer 12 month old vaccines (MMR, Varicella, PCV20)
• Follow up at 15 month well child check

.15mwcc

15 Month Well Child Check

• Growing and developing normally
• Administer 15 month vaccines (Hep A and Hib)
• Follow up at 18 month well child check

.2yowcc

2 year old well check

• Growing and developing normally
• MCHAT obtained and normal today
• SPOT Vision normal today
• Lead screening questionnaire normal
• Administer 2 year old vaccines today (Hep A #2)
• Follow up at the 2.5 year old well check

.4yowcc

4 Year Old Well Child Check

• Growing and developing normally
• Vision screen normal
• No parental concerns today
• Administer 4 year old vaccines (Dtap, IPV, MMR and Varicella)
• Follow up in 12 months for next well child check

.5yowcc

Kindergarten Well Check

• Growing and developing normally
• Hearing screen passed and normal
• UTD on vaccines, recommended year influenza vaccine when appropriate
• Follow up in 1 year for next wcc

.11yowcc

11 Year Old Well Child Check

• Growing and developing normally
• Parental and parent concerns discussed and addressed as above in history
• Administer MCV4 and TdaP today
• Discussed HPV vaccine and family plans to receive prior to age 15, will readdress at next annual visit
• Passed hearing and vision screens today
• Middle school physical form given
• Follow up in 1 year

.16yowcc

16 Year Old Well Check

• Growth and development on track
• Parental and patient concerns addressed today
• GAD7 and PHQ9 obtained and _________
• Administered MCV4 booster and MenB vaccines today
• Follow up in 1-2 months for MenB#2 as a NV
• Follow up in 1 year for next well check

.newbornfpe

General: Infant awake and alert
Eyes: Pupils equal round and reactive bilaterally, red reflex bilaterally, no scleral icterus
Head and Neck: Normocephalic, anterior fontanelle open soft and flat
ENT: Ear canals patent without erythema or discharge
CV: Heart regular rate and rhythm without murmurs, rubs or gallops
Respiratory: Lungs clear to auscultation bilaterally without wheeze or crackle
Skin: No abnormal rashes, lesions or bruises
GU: Normal external female genitalia without discharge
Abdomen: Soft, no masses palpated, no organomegaly. Umbilical stump intact without erythema or drainage
Hips: Negative Barlow and Ortolani
MSK: Moving all extremities normally, no step-offs on spine or dimples

.newbornmpe

General: Infant awake and alert
Eyes: Pupils equal round and reactive bilaterally, red reflex bilaterally, no scleral icterus
Head and Neck: Normocephalic, anterior fontanelle open soft and flat
ENT: Ear canals patent without erythema or discharge
CV: Heart regular rate and rhythm without murmurs, rubs or gallops
Respiratory: Lungs clear to auscultation bilaterally without wheeze or crackle
Skin: No abnormal rashes, lesions or bruises
GU: Normal male penis with testicles palpable bilaterally
Abdomen: Soft, no masses palpated, no organomegaly. Umbilical stump intact without erythema or drainage
Hips: Negative Barlow and Ortolani
MSK: Moving all extremities normally, no step-offs on spine or dimples

.infantfpe

General: Infant awake and alert
Eyes: Pupils equal round and reactive bilaterally, red reflex bilaterally, no scleral icterus
Head and Neck: Normocephalic, anterior fontanelle open soft and flat
ENT: Ear canals patent without erythema or discharge
CV: Heart regular rate and rhythm without murmurs, rubs or gallops
Respiratory: Lungs clear to auscultation bilaterally without wheeze or crackle
Skin: No abnormal rashes, lesions or bruises
GU: Normal external female genitalia without discharge
Abdomen: Soft, no masses palpated, no organomegaly. Umbilical stump intact without erythema or drainage
Hips: Negative Barlow and Ortolani
MSK: Moving all extremities normally, no step-offs on spine or dimples
Neurologic: Moro reflex intact, palmar and plantar reflexes present

.infantmpe

General: Infant awake and alert
Eyes: Pupils equal round and reactive bilaterally, red reflex bilaterally, no scleral icterus
Head and Neck: Normocephalic, anterior fontanelle open soft and flat
ENT: Ear canals patent without erythema or discharge
CV: Heart regular rate and rhythm without murmurs, rubs or gallops
Respiratory: Lungs clear to auscultation bilaterally without wheeze or crackle
Skin: No abnormal rashes, lesions or bruises
GU: Normal male penis, testicles palpable bilaterally
Abdomen: Soft, no masses palpated, no organomegaly. Umbilical stump intact without erythema or drainage
Hips: Negative Barlow and Ortolani
MSK: Moving all extremities normally, no step-offs on spine or dimples
Neurologic: Moro reflex intact, palmar and plantar reflexes present

.toddlerfpe

General: Patient awake and alert, in no acute distress
Eyes: Pupils equal round and reactive to light bilaterally, EOMI
ENT: Bilateral TM’s clear without erythema or bulge, nares parent without rhinorrhea, posterior oropharynx without erythema or exudate
CV: Heart regular rate and rhythm without murmurs, rubs or gallops
Respiratory: Lungs clear to auscultation bilaterally without wheeze or crackle
Skin: No abnormal rashes, lesions or bruises
GU: Normal external female genitalia without discharge
Abdomen: Soft, nontender, no masses palpated, no organomegaly
MSK: Moving all extremities normally

.toddlermpe

General: Patient awake and alert, in no acute distress
Eyes: Pupils equal round and reactive to light bilaterally, EOMI
ENT: Bilateral TM’s clear without erythema or bulge, nares parent without rhinorrhea, posterior oropharynx without erythema or exudate
CV: Heart regular rate and rhythm without murmurs, rubs or gallops
Respiratory: Lungs clear to auscultation bilaterally without wheeze or crackle
Skin: No abnormal rashes, lesions or bruises
GU: Testicles palpable bilaterally, normal male penis without discharge
Abdomen: Soft, nontender, no masses palpated, no organomegaly
MSK: Moving all extremities normally

.childfpe

General: Patient awake and alert, in no acute distress
Eyes: Pupils equal round and reactive to light bilaterally, EOMI
ENT: Bilateral TM’s clear without erythema or bulge, nares parent without rhinorrhea, posterior oropharynx without erythema or exudate
CV: Heart regular rate and rhythm without murmurs, rubs or gallops
Respiratory: Lungs clear to auscultation bilaterally without wheeze or crackle
Skin: No abnormal rashes, lesions or bruises
GU: Normal external female genitalia without discharge.
Abdomen: Soft, nontender, no masses palpated, no organomegaly
MSK: Moving all extremities normally, normal gait, no scoliosis noted

.childmpe

General: Patient awake and alert, in no acute distress
Eyes: Pupils equal round and reactive to light bilaterally, EOMI
ENT: Bilateral TM’s clear without erythema or bulge, nares parent without rhinorrhea, posterior oropharynx without erythema or exudate
CV: Heart regular rate and rhythm without murmurs, rubs or gallops
Respiratory: Lungs clear to auscultation bilaterally without wheeze or crackle
Skin: No abnormal rashes, lesions or bruises
GU: Testicles palpable bilaterally, normal male penis without discharge
Abdomen: Soft, nontender, no masses palpated, no organomegaly
MSK: Moving all extremities normally, normal gait, no scoliosis noted

.teenfpe

General: Patient awake and alert, in no acute distress
ENT: Bilateral TM’s clear without erythema or bulge, nares parent without rhinorrhea, posterior oropharynx without erythema or exudate
CV: Heart regular rate and rhythm without murmurs, rubs or gallops
Respiratory: Lungs clear to auscultation bilaterally without wheeze or crackle
Skin: No abnormal rashes, lesions or bruises
GU: Normal external female genitalia without discharge. Tanner stage __________
Abdomen: Soft, nontender, no masses palpated, no organomegaly
MSK: Moving all extremities normally, normal gait, no scoliosis noted

.teenmpe

General: Patient awake and alert, in no acute distress
ENT: Bilateral TM’s clear without erythema or bulge, nares parent without rhinorrhea, posterior oropharynx without erythema or exudate
CV: Heart regular rate and rhythm without murmurs, rubs or gallops
Respiratory: Lungs clear to auscultation bilaterally without wheeze or crackle
Skin: No abnormal rashes, lesions or bruises
GU: Testicles palpable bilaterally, no hernias palpated during Valsalva or cough, normal male penis without discharge, Tanner Stage ___________
Abdomen: Soft, nontender, no masses palpated, no organomegaly
MSK: Moving all extremities normally, normal gait, no scoliosis noted

.adhd

ADHD

• Doing well on current medication plan
• Discussed medical benefits of treatment and current side effects for patient
• KASPER reviewed and appropriate
• Continue currently prescribed medication as above
• Follow up in 4 months or sooner if concerns

.adhdpe

General: Patient awake and alert, in no acute distress
Eyes: Pupils equal, round and reactive to light bilaterally. No conjunctival injection or scleral irritation
CV: Heart regular rate and rhythm without murmurs, rubs or gallops
Respiratory: Lungs clear to auscultation bilaterally without wheeze or crackle

.adhdstart

ADHD

• Vanderbilt’s, patient history and family report all consistent with ADHD diagnosis
• Discussed treatment options and recommendations including a 504 plan or equivalent, therapy, and medication options
• Will plan to start medical treatment as above. Discussed risks and benefits of treatment
• Family to call in 7-10 days with update on medication performance
• Follow up in ___________

.allergicconjunctivitis

Allergic Conjunctivitis

• Signs of symptoms of allergy related symptoms
• Very unlikely to be bacterial given the constellation of patient’s presentation
• Recommend Pat A Day allergic eye drops for the next 2-3 weeks
• Can add daily oral 2nd generation antihistamine such as Loratadine or Cetirizine as well
• Call if worsening or with further concerns

.allergies

Allergic Rhinitis

• History and exam consistent with allergies
• Recommended OTC allergy medication such as Zyrtec or claritin, following dosing recommendations for age
• If not improving or concerns can call clinic for further evaluation

.attest

Attestation: I was present during the visit. I discussed the case with the Tristen Morrow, APRN and agree with the note as documented above for history, physical exam, diagnosis and plan.

.atypical

Atypical Pneumonia

• Patient presents with history and exam concerning for atypical pneumonia
• Start antibiotics as above
• Recommended good hydration and monitoring of symptoms.
• Cough may take several days to a few weeks to fully improve
• Call with changes or concerns

.bedwetting

Nocturnal Enuresis

• Discussed that this is still very normal at this age
• Only data driven aids are bed wetting alarms
• Discussed the use of these
• Parents to call with concerns

.bronchiolitis

Bronchiolitis

• Patient presents with history and exam consistent with bronchiolitis
• Discussed the various different viral etiologies and testing was _________
• Recommended saline and suction to control secretions
• Encouraged good hydration with fluids with a goal of at least 3 good wet diapers in a 24 hour period
• Discussed increased work of breathing and concerning features that would lead to recommendation to go do the ED
• May use tylenol and ibuprofen as needed
• Call with concerns.

.chap

Sensitive exam portions were chaperoned by _______________

.conjunctivitis

________ Conjunctivitis

• Start antibiotic drops as above
• Symptoms should be improving and on antibiotic drops for at least 24-48 hours before returning to school or daycare
• Call with any changes or concerns.

.constipation

Constipation

• Exam and history consistent with constipation
• Given the short/prolonged time period for symptoms would/would not recommend full clean out
• Recommended starting 1 capful miralax once daily and titrate to soft, ice cream consistency, stools
• Continue this for the next 6-8 weeks for full resolution of symptoms.
• Also should increase water intake to at least 60 ounces of water per day
• If not improving over the next 7-10 days, call for further evaluation

.croup

Croup

• Signs and symptoms consistent with croup
• History concerning for stridor and possible changes in work of breathing
• Start steroids as above
• Counseled that cool air and moist air both can aid greatly for stridor
• Strict return precautions given regarding work of breathing or breathing changes

.flu

Influenza _____

• Patient presents with concerning signs for influenza
• Rapid Flu positive
• Discussed medical treatment options including prescribing Tamiflu. Risks and benefits of treatment were discussed including potential for nausea and vomiting.
• Start Tamiflu today as above
• Parents declined treatment today
• Encouraged good hydration, treat with Tylenol and ibuprofen, and to watch for increased work of breathing.
• Call with questions or concerns

.gastro

Gastroenteritis

• Patient presents with history and exam concerning for viral gastroenteritis
• Recommended BRAT diet and encouraged fluids
• May take several days to resolve and if significant diarrhea to not consume any dairy until resolved for 48 hours
• Call with questions or concerns

.granuloma

Umbilical Granuloma

• No signs of infection at this time
• Discussed treatment options with family and cauterization was mutually decided as best treatment
• Risks and benefits of the procedure were discussed with parent. Silver nitrate was applied to the umbilicus until resolution of drainage was noted. Infant tolerated the procedure very well. There were no complications. Recommended no submerged bath for 48 hours.
• Family will call with questions or concerns

.hfm

Hand, Foot and Mouth

• Symptoms and exam consistent with hand, food and mouth
• Hydration status is _________
• Lesions will resolve over the course of 1-2 weeks, sometimes with peeling. Recommending hydrating skin
• Can return to activities once afebrile for 24 hours and any blistered lesions are resolving
• Call with questions or concerns.

.infanturi

Viral Upper Respiratory Infection

• Symptoms consistent with viral upper respiratory infection
• No significant work of breathing or retractions noted
• Recommended good amounts of saline and limit suction to 3-4 times per day
• Encouraged good supportive care with appropriate hydration and analgesics as needed (tylenol)
• Return precautions given, call with concerns

.lom

Left Otitis Media with _____________

• Exam and history concerning for otitis media with/without systemic symptoms
• Start antibiotics per dosage above
• Continue supportive care with good hydration and pain control as needed
• Return precautions given (At least 3 urinations per 24 hours, improvement of symptoms of 3-4 days, etc)
• Family to call with any questions or concerns

.lymph

Lymph: Shotty submandibular and anterior cervical lymphadenopathy bilaterally, largest node 3-4 mm in diameter

.otitisexterna

Otitis Externa

• Exam and history consistent with otitis externa
• Start external ear drops as above
• Counseled to wear ear plugs while swimming during treatment
• Call if not improving or with concerns

.return

• Return precautions given, call with changes or concerns

.rom

Right Otitis Media with _____________

• Exam and history concerning for otitis media with/without systemic symptoms
• Start antibiotics per dosage above
• Continue supportive care with good hydration and pain control as needed
• Return precautions given (At least 3 urinations per 24 hours, improvement of symptoms of 3-4 days, etc)
• Family to call with any questions or concerns

.sinusitis

Bacterial Sinusitis with _____________

• Patient symptoms consistent with sinusitis, signs of systemic illness given __________
• Start antibiotic as prescribed above
• Counseled symptoms may take several days to abate, and should continue symptomatic treatment as needed
• May return back to school as tolerated

.sports

Sports Physical

• Normal vision and vitals
• Normal physical exam without concerning findings
• History obtained via KHSAA sports physical documentation and attached
• Cleared for all athletic activity at this time

.strep

Strep Pharyngitis

• Rapid strep test positive
• Start antibiotics as prescribed above
• Recommended supportive care (hydration, antipyretics and analgesics as needed)
• While data may be limited recommended changing toothbrush prior to completing antibiotics as well as wash all bedding, stuff animals, etc that are frequently in use as part of routine cleanliness following illness.
• Return precautions given, family to call with concerns

.thrush

Oral Thrush

• Exam and history concerning for thrush
• Start nystatin as prescribed above
• Sterilize all bottles, pump equipment, pacifiers, etc nightly
• Call if not improving or with any other concerns

.uri

Viral Upper Respiratory Infection

• Symptoms consistent with viral upper respiratory infection
• Recommended over the counter treatments as appropriate for age
• Encouraged good supportive care with appropriate hydration and analgesics as needed
• Return precautions given (Improvement in symptoms over next 4-5 days, down-trending of fever by day 5, etc)

.viralpharyngitis

Viral Pharyngitis

• Rapid Strep Negative, culture pending
• Will follow up on culture at 24 and 48 hours, contacting family if positive and will start appropriate antibiotics
• Likely viral etiology with current findings
• Recommended good supportive care, antipyretics as need, including Tylenol and ibuprofen
• Continue good hydration and diet as tolerated
• Return back to school once afebrile for 24 hours and symptoms resolving