Chief Complaint This Question & Answer Guide (With Explanation)
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Key Explanation
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Original Question
CHIEF COMPLAINT: This male presented today for a health maintenance exam. Patient was accompanied by mother. The child eats 3 meals a day plus 2 snacks and is off the bottle. He sleeps through the night. He takes morning and afternoon naps. Mother is concerned about child’s red, matted eye and not walking completely alone yet. Immunizations need to be updated at today’s visit. DEVELOPMENTAL MILESTONES: 1 year developmental milestones reached: bangs blocks together, drinks from cup, eating finger foods, feeds self, gives toys on request, imitates vocalizations, looks for dropped or hidden objects, points to desired objects, pulls to stand and cruises, releases cube into cup after demonstration, says “mama” and “dada” with meaning, says one or two other words, tries to build tower of 2 cubes and waves bye. ALLERGIES: No known medical allergies. MEDICATIONS: None. PMH: Past medical history is unremarkable. PSH: No previous surgeries. FAMILY HISTORY: Patient admits a family history of cancer associated with maternal aunt, hypertension associated with paternal grandfather. SOCIAL HISTORY: He lives at home with parents. Mother admits bringing patient to daycare. REVIEW OF SYSTEMS: No change since last visit PHYSICAL EXAM: Temp: 97.6 Height: 0 ft. 31 in. Weight: 28 lbs. BMI: 20 Growth Chart Entry: Weight: 28 lbs 0 ozs Height: 0 ft 31 in Head Circumference: 18.50 in Patient is a 1 year-old male who appears in no apparent distress, well developed and well nourished. Inspection of head and face shows anterior fontanel normal, posterior fontanel normal and head is normocep
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