CCCCC

Patient:

Date of Birth: Date:

Historian:

Visit Type:

mother Wellchild

ores

History of Fresent Illness 1. 2 month Wel! child

Translated by Stephanie, MA. 2 month old female here with mother for comprehensive 2

month history and physical

lnterval history: concerns: Developed a rash on chest 2 weeks ago, has tried a cream from

Mexico starting yesterday. Mild improvement Diet: Breastfed, formulated with formula. Feeding every 3 hours, 4 ounce per feed when using

formula. Breastfed at night Stooling pattern: 3x/daily, normal Urinating freq. 8-10 wet diapers daily

Sleep pattern: sleeps throughout the night, wakes twice for feedings. 2-3 naps during the day

G rowth/development: lifts head 45 degrees when prone,

smiles responsively (social)

follows past midline, tracks kicks and grasps

Sreening Tools Other Screenings Encounter Performed Date Date

os/1812023 AslB/2A23

Screening Tqgl , ..,

PEARLS (Pediatric ACEs

and Related Life Events

Screener)CHILD

Scs*E

0

S.gy,gqtv/ ,

lntl$fbtation MOD':'.-,.,,,.Si5nhed' Classification Document

N

Medications (active prior to today) Medication Naine Sig Description Start Dat!: 1, S,lop Date Refilled ,. Rx Elsewhere

Saline Mist 0.65 % nasal spray 2 drop by nasal route 03/20/2023 spray aerosol every 2 hours

Developmental History

Developmental stage testing this visit reveals Age Group Age At Test Milestone llnal :Or* Comment

2 Months 2 Months 29 Days Makes sounds that let you ll#rtrrn- ::il;r., know he or she is happy or u pset

2 Months 2 Months 29 Days Seems happy to see you See graph* very much 2 Months 2 Months 29,Days Follows a moving toy with his See graph* very much

or her eyes

2 Months 2 Months 29 Days Turns head to find the person See graph* very much who is talking

2 Months 2 Months 29 Days Holds head steady when See graph* very much being pulled up to a sitting position

2 Months 2 Months 29 Days Brings hands together See graph* very much 2 Months 2 Months 29 Days Laughs See graph* very much 2 Months 2 Months 29 Days Keeps head steady when held See graph* very much

in a sitting position 2 Months 2 Months 29 Days Makes sounds like "ga," See graph* very much

"mar" or "ba" 2 Months 2 Months 29 Days Looks when you call his or See graph* very much

her name

Other Development Screenings

Date " Screening Name Results Entered by Comments

05/18/2023 2 Months - Milestones Pass 8/Fail 0 05/78/2023 Ages and Stages Questionnaire continued surveillance Sheyanne Espiritu A5/1,8/2023 2 Months - SWYC See graph* Alma Gomez, MA 05h812O23 Ages and Stages Questionnaire normal range Alma Gomez, MA

Review of Systems System Neg/Pos Details

Constitutional Negative Fever, Fussiness and lrritability. ENMT Negative Ear drainage, Nasal congestion, Rhinorrhea and Sneezing.

Eyes Negative Eye discharge and Eye redness. Respiratory Negative Cough, Sputum and Wheezing. Cardio Negative Coolextremity, Cyanosis and lrregular heartbeat/palpitations, Gl Negative Constipation, Diarrhea and Vomiting. GU Negative Decreased urine output. Psych Negative Behavioral changes.

I :.'- --- I^:'- :::::::::::: :: .:::.:a:: :: .'::::::: - - -

N

lntegumentary Positive Rash (Location: chest. Status: worse).

lntegumentary Negative Skin lesion and Urticaria. MS Negative Muscle weakness.'

Hema/Lymph Negative Easy bleeding, Easy bruising, Lymphadenopathy and Petechiae.

Allergic/lmmuno Negative Allergic rhinitis, Environmental allergies and Food allergies.

Vital Signs Height Time ft in cm Last Measured Height Position %

12:39 PM 2.0 0,00 60.96 A5lB/2023 Lying 7s.7

Weisht/BsA/BM! Time lb oz , kg Context weight% BSA m2

12:39 PM 13.00 7.0 6.095 undressed with 66.9 diaper

Temperature/Pu lse/Respiration Time Temp F Temp C Temp Site Bulse/min Pattern Resp/ min

L2:39 PM 97.4A 36.33 ear

Head/Neck/Waist/H ip Circu mference Time Head cm % Neck cm Waist cm Hip cm Waist/Hip

in in in in

12:39 PM 15.50 39.37 49.3

Measured by Time Measured by

12:39 PM Alma Gomez, MA

Physical Exam Exam Findings Details

PEDS UNDER 3YR Comments rash extending to chest

Constitutional Normal No acute distress. Well nourished. Well developed.

Head/Face * Anterior fontanel - Open, soft. Posterior fontanel - Open.

Head/Face Normal Skull - Normal. Eyes Normal Conjunctiva - Right: Normal, Left: Normal. Sclera - Right: Normal, Left:

Normal. Red reflexes - Present and symmetric bilaterally. Pupil - Right:

Normal, Left: Normal. Ocular muscles - Rlght: Normal, Left: Normal.

Ears Normal lnspection - Right: Normal, Left: Normal. Canal - Right: Normal, Left:

Normal. TM - Right: Normal, Left: Normal.

Nasopharynx Normal Nares - Right: Normal, Left: Normal. Nasal mucosa - Normal.

Lips/teeth/gums - Normal. Palate & uvula - Normal. Tonsils - Normal.

Oropharynx - Normal. Neck Exam Normal Range of motion - Normal. Lymph Detail Normal No palpable cervical, supraclavicular, or axillary adenopathy.

Respiratory Normal Auscultation - Normal. Cough - Absent. Effort - Normal. Cardiovascular Normal Heart rate - Regular rate. Rhythm - Regular. Murmurs - None. Vascular Normal Pulses - Brachial: Normal, Femoral: Normal. Capillary refill - less than 2

seconds. Abdomen * Inspection - reddened area(s). Abdomen Normal Auscultation - Normal. Anterior palpation - Normal. No guarding. No

rebound. No abdominal tenderness. Genitourinary * External genitalia - irritation. Genitourinary Normal Vagina - Normal. Skin * General inspection: rash on abdomen Spine * Back inspection - no abnormality. Musculoskeletal Normal Hip - Right: Normal, Left: Normal. Extremity Normal No cyanosis. No edema. Clubbing - Absent. Neurological Normal DTRs - Normal. Newborn reflexes present and normal - Sucking, Moro,

Rooting, Grasp. Psychiatric Normal Behavior is appropriate for age.

lmmunizations lmmunization Administered By Completed Date VIS Given Version Date of VIS Route Site Pneumococca Guevara, MA, 5/18/2023 lntramusc ORAL l, PCV-13 Ricardo 2:28:38 pM ular Hib (PRP-T) Guevara, MA, 5118/2an tntramusc Right

Ricardo 2:27:47 PM ular Thigh Rotavirus (3 Guevara, MA, 5118/2023 Oral Right dose) Ricardo 2:27:33 PM Thigh Pediarix Guevara, MA, 5118/2023 lntramusc LeftThigh

Ricardo 2:26:36 PM ular lmmunization Manufacture Lot Number Credential CVX Comments

r s Code

Pneumococca Pfizer, lnc FM5699 133 I, PCV-13

Hib (PRP-T) sanofi UJ801AA 48 pasteur

RotaviruS (3 Merck and W004502 11,6

dose) Co., lnc. Pediarix GlaxoSmithKl GT39Z 110

ine

lmmunizations Entered by History Date lmmunization 2/191202312:00:00 AM hepatitis B vaccine, unspecified formulation

Completed Orders (This Visit) Order Details Reason Side lnterpretation Result

PEARLS

(Pediatric ACEs

and Related

Initial Region

Treatment Date

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Life Events

Screener)

CHILD

Age

appropriate anticipatory guidance

discussed (2

Months)

Assessment/Plan # DetailType Description

1. Assessment Encounter for routine child health examination without abnormal findings (200.1.29).

Patient Plan Pediarix, PCV-13 #1, HiB #1, Rotavirus oral vaccination given, current VIS sheets offered to parent/guardian Vaccine reactions, risks and follow-up explained, Current VIS offered to guardian Nutritional assessment made Counseling: safety - never leave alone on high surface, car seat backward until 2 yrs old,

aceta m inophen dosi ng reviewed Diet - breast vs. formula feeding, no milk or honey till 1 y/o, no bottle recumbent, feeding position, colic, no solid foods until 4 - 6 months Behavior - crying, thumb sucking, no discipline yet Accident prevention - rolling, playpen use, burns from hot liquids Guidance - fever, acetaminophen dose, hot water temp 120deg F, No smoking in home

Safety precautions - infant car seat, water safety, falls, nursery equipment Pa rental smoki ng discussed

Childcare plan reviewed Emergency care plan reviewed Sibling and family relationships discussed

Thermometer use reviewed - rectal temp. No longer a medical emergency if child develops a fever lnfant care (bathing, skin, clothing) reviewed

ASQ problem solving score noted to be 20 at this visit, continue surveillance for now and

repeat assessment at 4 month wellness visit.

2. Assessment Rash (R21).

Patient Plan Hydrocortisone cream sent to pharmacy, advised mother to monitor rash for any worsening changes or accompanying symptoms such as fever or pain

3. Assessment Encounter for immunization (223).

Plan Orders Hib (PRP-T)Status:Administered; Pediarix Status: Administered; Pneumococcal, PCV-13

Status: Adm inistered; Rotavirus (3 dose) Status: Ad m inistered.

Anticipatory Gu idance: Age Group Anticipatory Guidance Category 2 Months Living situation and food security Social Determinants of Health

2 Months Family support Social Determinants of Health

2 Months Child care Social Determinants of Health

2 Months General guidance on feeding and delaying solid Nutrition and Feeding

foods

2 Months 2 Months 2 Months 2 Months 2 Months 2 Months 2 Months 2 Months 2 Months 2 Months 2 Months 2 Months 2 Months 2 Months

Hunger and satiety cues Nutrition and Feeding

Breastfeeding or formula-feeding guidance Nutrition and Feeding

Postpartum checkup Maternal depression Sibling relationships Parent-infant relationship

Parent-infant communications Sleeplng Media

Playtime

Fussi ness

Car safety seats

Safe sleep

Safe home environment: burns, drowning, and falls Safety

Parent and Family Health Parent and Family Health

Parent and Family Health

lnfant Behavior and Development lnfant Behavior and Development lnfant Behavior and Development lnfant Behavior and Development lnfant Behavior and Development lnfant Behavior and Development Safety

Safety

Medications (Added, Continued or Stopped today) Start Date Medication Directions

05/18/2023 hydrocortisone 0.5 apply by topical route 2 N

% topical cream times every day a thin layer

to the affected area(s)

03/20/2023 Saline Mist 0.65 % spray 2 drop by nasal N

nasal spray aerosol route every 2 hours

Active Patient Care Team Members Name Contact Agency Support Relationship Active Date lnactive Specialty

Type Role Date

DAMARIS Mother FLORES LOPEZ

Provider Patient PCP *Outside provider

Provider Bishop, Weave A5/18/2An 4:51 PM

Document generated uv@€#ffisrl P 05/78/2023 04:51 PM

PRN PRN Reason lnstruction Stop Date

Status

' '^.--^-r^- cr^.o. enrin 0OOOOOI?107? n)/1q/2023 OS/19/2023 1.1 :30 AM G/6