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Medical Record Documentation of Failure to Thrive

Name: Melinda Turner

Date of birth: March 16, 1993

Source of history: Parents, record from army

Immunizations: Complete except tuberculin skin test (see immunization record)

Drug allergies: None known

Tuesday, February 1, 1994

CHIEF COMPLAINT: "To check on her weight."

PRESENT ILLNESS: Seen here for first time on 1/27/94 for otitis media. Noted to be thin, with weight of 15 lb 7 oz [below 5th percentile; was 14 lb 8 oz (25th) at 6 months] and height of 28frac12 in [50th percentile; was 26 in (50th) at 6 months]. Parents say she has looked skinny "for months." Returns today with food diary for evaluation.






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Copyright © 1994 by the American Academy of Pediatrics.