Progress Notes

Vicky Ruleman, MD at 7/20/2022  3:20 PM

 
 
Subjective

 
Chief Complaint
Well Visit (15 yr)
 
History of Present Illness
Olivia is a 15yr 10mo female who presents to the office with her mother.
 
 

Review of Systems
Negative except as in HPI.
 
Development
demonstrates behaviors that contribute to a healthy lifestyle
has positive engagement with community
shows self confidence, hopefullness, well-being, and resiliency when confronted
with life stressors
is increasingly responsible and independent decision making
demonstrates physical, cognitive, emotional, social, moral competencies
has caring, supportive relationships with family, other adults, peers.
Anticipatory Guidance
Discussed: physical growth and development, social and academic competence,
emotional well being, risk reduction, physical activity and nutrition, violence and
injury prevention and sexual activity, safe sexual practices, healthy
relationships, and counseled regarding drugs, tobacco, and alcohol.
 
Diet, Elimination, Education, Activities, Home Environment
DIET: healthy balanced diet, vegetables, cow's milk, fruits
ELIMINATION: regular soft stools, normal urine output
SLEEP: sleeps well No snoring
SCREENTIME: instagram, tik tok Mom follows
DENTAL CARE: brushes 1-2 times per day, patient has a dental home
EDUCATION: Swampscott High 10th grade All As
ACTIVITIES: Softball (CF)
HOME SAFETY: No second hand smoke exposure. Properly
restrained in the car.
 

Social History
.
 

 
Lives w/ mom, dad, sister (Kaela)
 
 
Teen Social History
Substance Use, Gender and Sexual Orientation
Tobacco: 1. Never in the last year
Vaping products: 1. Never in the last year
Alcohol: 1. Never in the last year
Marijuana: 1. Never in the last year
 
Gender and Sexual Orientation:
Patient's sexual Orientation: Straight (not lesbian or gay)
Patient's gender identity: Female
Patient's sex assigned at birth: Female
Patient's pronouns: she/her/hers
 

Sexual Activity
 
Substance and Sexual Activity
Sexual Activity
Never
 
Menstrual History
LMP: 7/15/22
Pattern: regular
 
 
 
Dysmenorrhea: None
Comments: On heavier side, needs 2 tampons a day and 2 pads during the day
 

 
Reviewed this visit
Problems | Medications | Allergies | Medical History | Surgical History |
Family History | Menstrual History | Substance Use History |
 

Problem List
Patient Active Problem List
Diagnosis
•
Other acne
•
Anxiety state
•
Congenital pes planus
•
Headache
•
Spider angioma
•
Nevus
•
Generalized anxiety disorder
•
Separation anxiety disorder
 
Medications
Marked as "Taking"
Medication
Sig
•
FLUoxetine 10 MG capsule
Take 1 capsule (10 mg total) by mouth once daily at approximately the same time
each day.
 
Allergies
No Known Allergies
 
Past Medical History
Past Medical History:
Diagnosis
Date
•
Asthma
11/19/2015
 
Surgical History
Past Surgical History:
Procedure
Laterality
Date
•
NO PAST SURGERIES
 
 
 
Family History
Family History
Relation
Problem
Age of Onset
•
Father
Hypertension
 
•
Maternal Grandmother
Asthma
 
•
Mother's Brother
Allergic rhinitis
 
 
 
Asthma
 
 
Diet, Elimination, Education, Activities, Home Environment
DIET: healthy balanced diet, vegetables, cow's milk, fruits
ELIMINATION: regular soft stools, normal urine output
SLEEP: sleeps well No snoring
SCREENTIME: instagram, tik tok Mom follows
DENTAL CARE: brushes 1-2 times per day, patient has a dental home
EDUCATION: Swampscott High 10th grade All As
ACTIVITIES: Softball (CF)
HOME SAFETY: No second hand smoke exposure. Properly
restrained in the car.
 
Social History
.
 

 
Lives w/ mom, dad, sister (Kaela)
 
 
 
 
Objective

 
Vital Signs
BP 110/66 (BP Location: Left arm, Patient Position: Sitting) | Ht 5' 4" (162.6 cm)
| Wt 123 lb 4 oz (55.9 kg) | LMP 07/15/2022 (Exact Date) | BMI 21.16 kg/m²
Manual Vision Screen (07/20/22)
Mass VAT Left Eye: Pass
Mass VAT Right Eye: Pass
Near Vision Both Eyes: 20/20
 
 
Physical Exam

General
Well appearing, interactive, good eye contact, no acute distress
HEENT
Normocephalic/atraumatic, TMs nl bilaterally, oropharynx clear, mucous membranes
moist, supple neck
Cor
Regular rate and rhythm, no murmurs
Lungs
Clear to auscultation bilaterally
Chest/Back
symmetric chest, Tanner 5, No scoliosis
Abdomen
Soft, non-distended, no organomegaly, normal bowel sounds
GU
Normal external female, Tanner 5
Extremities
Warm, well perfused
Skin
No rash
Neuro
Normal tone, symmetric movements
 
 
 
 
Labs
Results for orders placed or performed in visit on 07/20/22
CBC
Result
Value
Ref Range
 
WBC
7.1
4.3 - 10.0 K/UL
 
RBC
4.80
4.09 - 5.48 M/uL
 
HGB
14.2
12.0 - 16.0 g/dl
 
HCT
43.4
37.0 - 47.0 %
 
MCV
90.4
80.0 - 97.0 fl
 
MCH
29.6
27.0 - 31.2 pg
 
MCHC
32.7
31.7 - 36.0 g/dl
 
PLT
264.0
140.0 - 440.0 K/ul
 
Neutrophils %
56.5
54.0 - 62.0
 
Lymph %
31.4
25.0 - 50.0
 
Monocytes %
10.0
4.7 - 12.0
 
Eosinophils %
1.6
0.0 - 3.0
 
Basophils %
0.4
0.0 - 1.0
 
Neutrophils Absolute
4.0
1.8 - 7.0
 
Lymphocytes Absolute
2.2
1.5 - 6.5
 
Monocytes Absolute
0.7
0.2 - 1.5
 
Eosinophil Absolute
0.1
0.1 - 0.3
 
Basophil Absolute
0.0
0.0 - 0.4
 
Immature Granulocytes %
0.1
0.0 - 1.0
 
Immature Granulocyte Absolute
0.0
 
 
RDW-CV
12.2
11.2 - 13.5 %
 
Labs Today
Results for orders placed or performed in visit on 07/20/22
CBC
Result
Value
Ref Range
 
WBC
7.1
4.3 - 10.0 K/UL
 
RBC
4.80
4.09 - 5.48 M/uL
 
HGB
14.2
12.0 - 16.0 g/dl
 
HCT
43.4
37.0 - 47.0 %
 
MCV
90.4
80.0 - 97.0 fl
 
MCH
29.6
27.0 - 31.2 pg
 
MCHC
32.7
31.7 - 36.0 g/dl
 
PLT
264.0
140.0 - 440.0 K/ul
 
Neutrophils %
56.5
54.0 - 62.0
 
Lymph %
31.4
25.0 - 50.0
 
Monocytes %
10.0
4.7 - 12.0
 
Eosinophils %
1.6
0.0 - 3.0
 
Basophils %
0.4
0.0 - 1.0
 
Neutrophils Absolute
4.0
1.8 - 7.0
 
Lymphocytes Absolute
2.2
1.5 - 6.5
 
Monocytes Absolute
0.7
0.2 - 1.5
 
Eosinophil Absolute
0.1
0.1 - 0.3
 
Basophil Absolute
0.0
0.0 - 0.4
 
Immature Granulocytes %
0.1
0.0 - 1.0
 
Immature Granulocyte Absolute
0.0
 
 
RDW-CV
12.2
11.2 - 13.5 %
 
 
Assessment/Plan

 
Assessment and Plan
Olivia was seen today for well visit.
 
Encounter for routine child health examination without abnormal findings (Primary)
- Brief Behavioral Assessment - Normal (PSC,PHQ9,Vanderbilt,etc)
 
Screening for iron deficiency anemia
- CBC; Future
 
Anxiety state
Assessment & Plan:
Improved with therapy and fluoxetine.
 
 

 
Follow-up and Dispositions
Return in about 1 year (around 7/20/2023) for Well Visit, sooner if needed.