Pediatric Medical Record

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Prepared by: [YOUR NAME]

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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

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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

• Chronic Conditions: None

• 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

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Growth and Development

Physical Growth

• Height: 34 inches

• Weight: 30 lbs

• Head Circumference: 48 cm

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

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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

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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

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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

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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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