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Health, 22.05.2020 19:59 shinyelish6

This 16-year-old presents today for his annual physical. This patient has been under my care since he was 6 years old. This patient has no known medical problems. Please see previous family history taken in May of last year. There are no additional items to add to that history. Social History The patient is a junior in high school and denies use of drugs or alcohol. He is a swimmer and trains year-round and is hoping to secure a college swimming scholarship. Denies any other social risk factors at this time. Patient was given patient educational materials on social risks that are relevant to his age. Physical Exam Vital Signs: As recorded by nurse. HEENT: Within normal limits. Neck: Examination and thyroid are normal. Abdomen: There are no masses or tenderness noted. Scar from previous appendectomy at age 12. Heart: Normal sounds, no murmurs. Musculoskeletal: There are no significant findings. Patient has better than average muscle strength and tone. No laboratory tests or procedures were ordered. Patient is current on all immunizations. Patient instructed to return in one year for physical, or sooner if an acute condition occurs. You should assign a code of to this case.

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