SU_NSG6435_W8_A3_Andre_T.docx - Name L.S Date Sex Male Age\/DOB\/PlaceofBirth:11.7 years Lake Wales FL SUBJECTIVE Historian Patient Mother present and

SU_NSG6435_W8_A3_Andre_T.docx - Name L.S Date Sex Male...

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Name: L.S.Date: 01/20/2020Sex: MaleAge/DOB/PlaceofBirth:11.7 years / 06-12-2008/ Lake Wales, FLSUBJECTIVEHistorian: Patient; Mother present and also giving historyPresent Concerns/CC:“L.S. is here to have his vaccines and yearly check-up.”Child Profile:L.S. is a well-developing, independent boy who is able to perform his activities of daily living, such as showering and brushing his teeth, without the help of his parents. He admits to wearing deodorant every day to school and showering every night. He is currently a Stage II on the Tanner Scale. He reports that he likes school and really enjoys his math class. He reports that he is making A and B grades in all classes. He admits that he recently joined the “running club” at school so that he can lose weight. He reports feeling self-conscious of what others say about him since he is overweight. His mother reports he has many male friends at school that sometimes spend the night with him. L.S.reports he always wears his seatbelt when he is riding in a vehicle. HPI:(must include all components)L.S. is an 11-year-old African American male presenting to the clinic today with his mother for his 11-year wellness exam and immunizations. L.S. reports he has been healthy the past year and cannot recall being sick. However, he is very overweight and reports he gets short of breath when performing vigorous activities, such as running or playing at P.E. Nutritional intake consists of plenty of meats, vegetables, and fruits, as well as sodas, juice, and tea. He denies the consumption of milk and reports he intakes very little water. His mother reports he is overall doing very well. L.S. denies a change in bowel or bladder routines. His mother reports that L.S. has been discussing his weight more with her and she can sense that he is concerned. She reports he is always saying he has “man boobs.” His mother is also concerned with his weight since he has gained 18 pounds since his last wellness exam in January 2019. L.S. reports his favorite foods are butter toast and fried shrimp. He admits to drinking 1-3 sprites per day and some apple juice when he gets home from school. He reports he hates water and “it has no taste.” He states he is sleeping well. He reports he retires around 8:30-9:00PM and wakes around 6:00-6:30AM on school days. He states he typically sleeps in on the weekends because he doesn’t retire until 10 or 11PM. L.S. and mother have no other concerns besides his weight gain at this time. Medications:(List with reason formed)NONEPMH: No past medical historyAllergies: AmoxicillinMedication Intolerances: NoneChronic Illnesses/Major traumas:NoneHospitalizations/Surgeries:NoneImmunizations:Up to date other than 11-year vaccinations that are scheduled at today’s visit.Family History (Please identify all immediate family)L.S..’s parents are both living. Both parents are obese. His mother has a history of hypertension and type 2 diabetes. His father has a history of hypertension, myocardial infarction x1, and stent placement x2. His paternal
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