Pediatric Medical Record
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Prepared by: [YOUR NAME]
Patient Information
Full Name: Erica Price
Date of Birth: January 15, 2087
Age: 2 years
Gender: Male
Patient ID: JD-2087-001
Address: Des Moines, IA 50301
Phone Number: 222 555 7777
Emergency Contact: Jane Price (Mother) - 222 555 7777
Primary Care Physician: Dr. Emily White
Medical History
Birth History
Gestational Age: 40 weeks
Type of Delivery: Vaginal
Birth Weight: 8 lbs 2 oz
Apgar Score: 8 at 1 minute, 9 at 5 minutes
Complications: None
Past Medical History
Surgeries/Hospitalizations: None
Allergies: No known allergies
Vaccinations: Up to date with all vaccines, including influenza and MMR
Medications: None
Family History
Parental Medical Conditions: Mother has asthma; Father is healthy
Siblings' Medical Conditions: None
Genetic Conditions: No known genetic conditions
Social History
Living Situation: Lives with both parents in a suburban home
School/Daycare: Attends Little Learners Daycare
Tobacco/Alcohol Exposure: No exposure to tobacco or alcohol
Other Social Factors: Family has a pet dog
Growth and Development
Physical Growth
Developmental Milestones
Motor Skills: Walks independently, runs with coordination, climbs stairs with assistance
Speech and Language: Says simple words like "mama," "dada," and can name a few objects
Social/Emotional: Shows interest in other children, exhibits separation anxiety
Cognitive: Follows simple directions, recognizes familiar faces and objects
Physical Examination
Parameter | Findings |
|---|
General Appearance | Well-nourished, active, alert |
Vital Signs | BP: 90/60 mmHg, HR: 110 bpm, RR: 24 breaths/min, Temp: 98.6°F |
Head | Normocephalic, atraumatic |
Eyes | Pupils equal, round, reactive to light and accommodation |
Ears | No signs of infection, bilateral hearing intact |
Nose/Throat | Clear, no nasal discharge, tonsils non-enlarged |
Chest/Lungs | Clear to auscultation, no wheezing or crackles |
Cardiovascular | Normal S1, S2, no murmurs |
Abdomen | Soft, non-tender, no masses or organomegaly |
Musculoskeletal | Full range of motion, no deformities |
Neurological | Alert, responsive, cranial nerves intact |
Skin | No rashes or lesions, warm and dry |
Genital/Urinary | Normal genitalia, no signs of infection |
Assessment and Plan
Assessment
Primary Diagnosis: Normal development for age
Secondary Diagnoses: None
Additional Considerations: Monitor speech development, no concerns at this time
Plan
Treatment: Continue healthy diet, encourage speech development activities like reading books
Referrals: None
Follow-up: Annual check-up in 6 months
Additional Testing: No additional testing needed
Progress Notes
Date of Visit: June 10, 2087
Summary of Visit: Patient presented for routine well-child check-up. No concerns raised by parents. Developmental milestones are on track. Growth parameters are within normal range.
Provider's Signature: Dr. Emily White
Provider's Credentials: MD, Pediatrician
Lab and Imaging Results
Test/Procedure | Date | Result |
|---|
CBC | June 9, 2087 | Normal, no abnormalities |
Vision Screening | June 10, 2087 | Pass, vision is normal |
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