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GUABA, RONALD
17 Y old Male, DOB: 12/23/1996
747 RIVERSIDE DRIVE, APT 5G, NEW YORK, NY-10031
Home: 212-368-4055
Guarantor: GUABA, RONALD Insurance: HEALTH FIRST
Payer ID: 80141
PCP: JUAN TAPIA MENDOZA
Appointment Facility: Pediatrics 2000 II PC 135

03/31/2014

Progress Notes: Robert Perello, MD

Current Medications

Reason for Appointment

1. bib mother, Physical Exam
2. Last PE 03/2013
3. CIR is asking for Flu.. Well Adolescent Visit (Male) 15-17 Years **

None

Past Medical History

Asthma- last asthma attack 2 years ago- mild
intermittent
BORN @ Presbyterian hospital, wbt 9lb and
2oz, normal delivery, breast feed, formula
and full term

Surgical History
Denies Past Surgical History

Family History
Father: unknown
Mother: alive 39 yrs migraine
Paternal Grand Father: deceased
Paternal Grand Mother: unknown
Maternal Grand Father: alive diabetes type 2
Maternal Grand Mother: alive high blood
pressure
2 sister(s) - healthy.
one sister asthma.

Social History
Tobacco Use:
Smoking Are you a: nonsmoker.
Headss-assesment:
Education: Grade 11, Peformance C
AVERAGE. Activities: play sports:
WRESTLING TEAM, Screen time (TV/Video
games/Computer) less than 2hours per day.
Sexual Behavior: attraction to females. Has a
boyfriend/girlfriend?: no. Drugs: denies.
Sexual Activity: not sexually active ever,
knows about STD's. Behavioral
Health/Suicidality: denies. Weight: Satisfied
with weight. Violence/Safety: denies. Home:
lives with parents, no social issues.
HEADSS ASSESMENT MANDATORY.

Allergies
N.K.D.A.

Hospitalization/Major
Diagnostic Procedure
asthma 1997

Patient: GUABA, RONALD

History of Present Illness

Depression Screening:
PHQ-9 Total Score 2, Intepretation Minimal Depression.
13 Year - 17 Year:
Interim History No significant history. Sleep No problems, sleeps
through night. Dental Dental care in the past year.
Elimination:
voiding normal. voiding normal. stooling normal. stooling normal.
Pediatric Nutrition:
Meals Consumed: 3 meals, plus 2 snacks per day, regular diet for
age. Does the child drink milk? Type: 1%, Amount: 1x. Does the child
drink juice or soda? Amount 3x or more, water.
Risk Assessment:
Tuberculosis Has your child been exposed to anyone with TB
disease? No, Does your child have close contact with a person who had
a positive test for TB infection? No, Has your child consumed dairy
products obtained from abroad such as raw milk or fresh cheese?
No, Does your child spend time with anyone who has been in jail or
prison or shelter, uses illegal drugs or has HIV? No, Was your child
born outside of the US? No, Has your child or household member
traveled outside of the US in a high TB incidence area for greater than 1
month? No. Cholesterol Does your child have parents or grandparents
who have had a stroke or heart problem before age 55? No, Does your
child have a parent with elevated blood cholesterol (240 mg/dL or
higher) or who is taking cholesterol medication? No. Anemia Does
your child's diet include iron rich food such as meat, eggs, iron fortified
cereals or beans? Yes, Hx of types of anemia that are passed down in
your family? No, Does your child suffer from a chronic illness? No.
History of Present Illness :
BIB by mother for annual physical. Pt doing well, no concerns at
this time.
Vital Signs
MA jg, Wt 204, Ht 72.25, BMI 27.47, BMI % 93.26, Temp 96.9, BP
119/56, HR 69.

DOB: 12/23/1996

Progress Note: Robert Perello, MD

03/31/2014

Note generated by eClinicalWorks EMR/PM Software (www.eClinicalWorks.com)

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4/30/2014

Page 2 of 3

Review of Systems
PEDIATRICS:
see HPI for details.

Examination
General Examination:
GENERAL APPEARANCE: well developed and well nourished,
pleasant, alert and oriented, NAD. HEENT: HEAD:, normocephalic,
EARS:,, tympanic membranes normal, EYES:, eyes normal, PERRL,
NOSE:, nose clear, THROAT:, pharynx and tonsils normal. ORAL
CAVITY: normal, TEETH:, normal dentition, no dental caries.
NECK: supple, no lymphadenopathy. HEART: RSR/RRR, normal
S1S2, no murmurs. CHEST: normal shape and expansion.
LUNGS: clear to auscultation bilaterally, no wheezes/rhonchi/rales,
good air exchange. ABDOMEN: soft, non-tender, no organomegaly,
bowel sounds are normal, no masses palpated. NEUROLOGIC
EXAM: non-focal exam, CN's II-XII grossly intact, normal strength,
tone and reflexes. SKIN: FACIAL ACNE. EXTREMITIES: normal
ROM, no abnormalities or deformities. BACK: normal, no evidence of
scoliosis. MALE GENITOURINARY: normal external male genitalia,
no scrotal masses, no hernias, SMR 5. PSYCH appropriate mood and
affect .
Assessments
1. ROUTINE MEDICAL EXAM - V70.0 (Primary)
2. COUNSELING NOS - V65.40
3. DIETARY SURVEIL/COUNSEL - V65.3
4. COUNSELING INJRY PREVENT - V65.43
5. EXERCISE COUNSELING - V65.41
6. COUNSLNG SBSTN USE ABUSE - V65.42
7. CONSLN OT SEX TRNSMT DIS - V65.45
8. ACNE - 706.1
Treatment
1. ROUTINE MEDICAL EXAM
Patient Educated with: PATIENT15-17yr.pdf (PATIENT15-17yr.pdf).
2. ACNE
Start Benzamycin Gel, 5-3 %, 1 application to affected area, Externally,
Twice a day, 14 days, 1 bottle, Refills 2
Immunization
Influenza, Injectable > 3 yr, quadrivalent (IIV4), PF given by
PERELLO,ROBERT on RA
Preventive Medicine
Teen anticipatory guidance: Domestic Violence . Drugs .
Eating/Body Image . Exercise . Gun Safety . Bicycle Helmet .
Nutrition/Weight . Biirth Control and STI risk reduction . Seat Belt
use . Testicular Self Exam . Tobacco Avoidance . Alcohol .
Hygiene . Injury Prevention . Physical Activity .
Depression/Suicide/Mental Health . Encourage School/Community
involvement ..
DISCUSSED AND/OR HANDOUT GIVEN.
Procedure Codes
99401 P/M COUNSEL, INDIV 15MIN
99420 HEALTH RISK ASSESSMENT TEST

Patient: GUABA, RONALD

DOB: 12/23/1996

Progress Note: Robert Perello, MD

03/31/2014

Note generated by eClinicalWorks EMR/PM Software (www.eClinicalWorks.com)

https://nytricapp.eclinicalweb.com/mobiledoc/jsp/catalog/xml/printChartOptions.jsp?enco...

4/30/2014

Page 3 of 3

99429 UNLISTED PREVENTIVE SERVICE

H0049 ALCOHOL/DRUG SCREENING
90686 influenza, inactivated virus vaccine, seasonal quadrivalent(IIV4)
split virus preservative free
90471 IMMUNIZATION ADMIN
Follow Up
1 Year, prn

Electronically signed by ROBERT PERELLO , MD on

03/31/2014 at 08:23 PM EDT
Sign off status: Completed

Pediatrics 2000 II PC 135

3332 Broadway
New York, NY 10031-8732
Tel: 212-694-2000
Fax: 212-690-7041

Patient: GUABA, RONALD

DOB: 12/23/1996

Progress Note: Robert Perello, MD

03/31/2014

Note generated by eClinicalWorks EMR/PM Software (www.eClinicalWorks.com)

https://nytricapp.eclinicalweb.com/mobiledoc/jsp/catalog/xml/printChartOptions.jsp?enco...

4/30/2014