H&P 2 (Site Evaluation)

Date: 01/06/2022

Full name: T.K 

Address: Jamaica, NY

Date of Birth: 05/20/2011

Location: Parson Pediatrics (Dr. Arana’s office)

Religion: Christian

Source of Information: Mother

Reliability: Reliable

Source of Referral: none

Mode of Transport: Parent

Chief Complaint: “Vomited at school yesterday” 

History of Presenting Illness:

Patient is a 10-year-old male with no PMHx brought into the office by his mother who complaints that he vomited once yesterday while at school and was sent back home afterwards. The patient threw up again at home but today only c/o feeling weak generally. The mother complains that he has not eaten properly since the vomiting started. The patient has not yet received the flu vaccine. The child is also due for an annual routine checkup. The child is currently not on any medications. There are no further complaints currently.

Past Medical History:

– Denies any PMHx 

Past Surgical History:

– Denies any Surgical hx or hospitalizations


– Not currently on any medication


-No known drug, food or environmental allergies.

Family History:

Mother – 36 years old and alive 

Father – 38 years old and alive 

2 Brothers and 6 sisters –all healthy 

Paternal Grandmother- alive but health hx is unknown.

Social history: 

– Lives with parents and siblings.

– Parents deny tobacco use and deny smoking 

– Parents deny any alcohol abuse.

– He is in the 5th grade

– He like soccer and plays with friends after school 

– He eats fruits and vegetables but also likes other foods like fried chicken, burritos, tacos etc. 

Review of system:

General – Poor appetite. Denies fever and chills. Denies Sleep disturbance.

Skin, hair, and nails- unremarkable

Head – denies headache  

Eyes – denies lacrimation, itching, pain 

Ears – denies ear pain 

Nose /Sinuses – denies any change in smell perception

Mouth/ throat – denies any pain 

Neck – denies any recent swelling 

Breast – did not ask  

Pulmonary system – denies difficulty breathing

Cardiovascular system – did not ask. 

Gastrointestinal system – change of appetite. Vomiting x 2

Genitourinary system – denies any frequent urination 

Menstrual /obstetrical – did not ask 

Nervous system – did not ask 

Musculoskeletal – denies any weakness in extremities 

Peripheral vascular system – denies any swelling around the legs 

Hematological – denies any anemia, easy bruising 

Endocrine system – denies any increased thirst, loss of appetite 

Psychiatric – did not ask 

Physical exam:

Vital signs: 

Using machine (Left arm while seated) BP: 98/62 mmHg

Pulse: 78 bpm, regular

RR: 12 breaths/min unlabored

T: 98F using forehead

O2 sat: 98% on room air 

BMI: Weight: 71lbs, Height: 53.5 inches = 17.44 

General: African American male is alert and oriented to place, appears in no acute distress, well nourished. Appears lethargic. Dressed appropriately for weather and age.

Skin, hair, and nails: good skin turgor, no cyanosis, or edema. No spoon nails. Normal capillary refill.

Head:  Atraumatic and normocephalic. Hair is black with good distribution. No seborrhea, lice, or mites. 

Eyes: PERRLA. Does not wear corrective lenses. No Icterus. No conjunctival injection. 

Ears: No swelling behind the ear or erythema noted around the auricle. No tenderness to palpation of the auricle. Cone of light was noted at 7 and 8 O’clock and there is no erythema or fluid noted. 

Nose: Patent bilaterally. No polyps or deviated septum noted. 

Neck: Supple, Full ROM. No tenderness to palpation. 

Throat: Uvula midline, Upper palate rises. 

Mouth: Oral mucosa is moist. No erythema or central cyanosis noted.

Pulmonary: Lungs were clear to auscultation Bilaterally. No rales or Rhonchi.

Cardiovascular: Normal S1 and S2 sounds. 

Abdominal exam: Abdomen is soft. Bowel sounds present in all four quadrants, No pain with light and no pain on deep palpation. 

Breast: Not applicable.

Genitourinary: Could not be performed.

Menstrual and Obstetrical: Does not pertain to the patient

Endocrine system: No goiter 

Neuro exam: Normal gait, Intact light touch, sharp/dull sensations. No tics, tremors, or fasciculation.

Musculoskeletal: Full ROM with 5/5 strength in both upper and lower extremities. 

Peripheral vascular system: +3 peripheral pulses. 


10-year-old male with no PMHx is brought in by mum with c/o of vomiting x 1 day. Pt is covid vaccinated but is due for influenza vaccination. Pt is in no acute distress currently. Pt is also due for routine annual exam. 


  1. Acute gastroenteritis
  2. Food poisoning 


–  Counsel on Brat diet and Rehydration 

– Administer Flu vaccine 

– Start Acetaminophen solution 10ml orally every 4 hours x 3 days. (prescribed for side effects of flu vaccine.)

– Start Chewable children’s multivitamin