HPI: 7-year-old male was recently evaluated in the clinic 4 weeks ago for headaches with aunt. He recently had a change in his home situation

HPI: 7-year-old male was recently evaluated in the clinic 4 weeks ago for headaches with aunt. He recently had a change in his home situation, parents are deceased from MVA and now living w/ aunt/uncle with 3 cousins. He is returning today with Aunt. Per Aunt, J.R. has had decrease in his grades, he continues to report headaches and goes to the school nurse at least twice weekly. At home he just sits and watches tv. He is quiet. His appetite has been decreased recently. He reports today all over headache and belly pain.

Past Medical History: Asthma, measles and mumps.

Allergies: Ibuprofen

Medications: Singulair 10 mg PO daily. Proair 1-2 puffs Q4H PRN wheezing.

Social History: Recently moved in with aunt, uncle & cousins (3 of them: 17, 15, 14). Mother/father deceased. Goes to public school, 2nd grade. No firearms, tobacco, alcohol, illicit drugs in home.

Family History: Mother and father deceased MVA, no medical history. Has no siblings. Health

Maintenance/Promotion: Up to date on immunizations. Had measle/mumps at the age of 4. ROS:

General. Denies fever, malaise. Denies night sweats or weight gain. Sleeping more.

Skin. Denies rashes, lesions, itching, ulcers/growths, bleeding, bruising, dryness or scales.

HEENT: Reports headaches and denies dizziness. Denies no changes in visual acuity, dryness or

pain. Denies ear pain, discharges, tinnitus and hearing loss. Denies nasal obstruction, discharges, and

bleeds. Denies sore throat, hoarseness, dysphagia, and throat pain. Denies any neck pain.

Cardiovascular. Denies pain to the chest area, palpitations, bruits, and murmurs.

Lungs. Denies cough, wheezing, and shortness of breath. Denies any asthma sx at this time.

Gastrointestinal. Denies nausea, vomiting, bloating, constipation, diarrhea, or changes in bowel habits.

Reports stomache unable to further explain. Aunt reports poor appetite.

Genitourinary. Denies dysuria, nocturia, hematuria, urinary hesitancy or frequency. Musculoskeletal:

Denies weakness or joint pain.

Neurologic. Denies any history of seizures. Reports head pain all over.

Endocrine. Denies temperature intolerance, polydipsia, polyuria, polyphagia, weight loss, weight gain.

Psychological. Misses his parents and is sad.

Hematological/Lymphatic. Denies abnormal bruising, bleeding, and no enlarge lymph nodes.

OBJECTIVE DATA

General. A well-dressed, clean male, awake, alert, oriented X 3. Looking to the ground.

VITAL Signs (VS). Temperature: 98.5 degrees Fahrenheit, temperature route: tympanic. Heart rate: 74

bpm. Respiratory rate: 15: Blood pressure: 99/65 mm/Hg. Oxygen saturation: 100% on room air. Weight:

40 lbs. Height: 52”.

Skin. Warm and dry to touch, color and turgor good, capillary refill +3. No rashes or lesions observed.

Skin tenting. No ecchymosis or trauma observed.

HEENT: Normocephalic, no tenderness during palpation, no lumps, lesions, or masses, hair thick with even distribution. PERRLA, conjunctiva clear and non-icteric. Tympanic membranes gray and intact with a cone of light noted. Pinna and tragus are non-tender. Nares with no exudate. Turbinate pink and moist. No tenderness to sinuses. Dry mucous membranes. Oropharynx no exudates, tonsils +1. Neck full ROM. Supple, no lymphadenopathy. Cardiovascular (CV). S1 and S2 are present. No gallops, opening snaps murmurs, or rubs. No pain with palpitation of chest wall.

Respiratory: Unlabored, bilaterally clear to auscultation. Gastrointestinal: Normoactive, bowel sounds heard in all four quadrants. Soft, non-distended. Non-tender, no palpable masses.

Genitourinary: Suprapubic non-tender, non-distended, no CVA tenderness.

Peripheral vascular: Extremities warm and dry and without edema.

Musculoskeletal. Full range of motion. No crepitus palpated.

Neurologic. Normal gait. Good muscle strength and tone. CN II-VII tact. Psych: Flat affect, soft spoken, poor eye contact.