SUBJECTIVE:
_-month old _ here for well child check. No parental concerns at this time.
REVIEW OF SYSTEMS:
- Diet: No concerns.
- Voiding/stooling: No concerns.
- Sleeping: Has regular bedtime routine, and sleeps through the night without feeding.
- Behavior: No concerns.
- Activity: Screen/TV time is limited to < 2 hrs/day.
PM/SH:
Normal pregnancy and delivery. No surgeries, hospitalizations, or serious illnesses to date.
DEVELOPMENT:
- Gross motor: Walking, starting to run, bends down without falling.
- Fine motor: Feeds self with a spoon, puts blocks in a cup, drinks from a cup with very little spilling.
- Cognitive: Follows simple directions, scribbles.
- Social/Emotional: Pretend play (e.g. phone), stranger anxiety, likes to copy older children and adults, tries to help.
- Communication: Knows at least 4 words, points to body parts, brings toys over to show you.
SOCIAL:
- No smokers in the home.
- No major social stressors at home.
- No safety concerns in the home.
- Daytime child care is with _
- No TB or lead risk factors.
IMMUNIZATIONS:
- Up to date.
OBJECTIVE:
- VITALS: _
- GEN: Normal general appearance. NAD.
- HEAD: NCAT.
- EYES: PERRL, red reflex present bilaterally. Light reflex symmetric. EOMI, with no strabismus.
- ENMT: TMs, nares, and OP normal. MMM. Normal gums, mucosa, palate. Good dentition.
- NECK: Supple, with no masses.
- CV: RRR, no m/r/g.
- LUNGS: CTAB, no w/r/c.
- ABD: Soft, NT/ND, NBS, no masses or organomegaly.
- GU: Normal _male genitalia. Testes descended bilaterally.
- SKIN: WWP. No skin rashes or abnormal lesions.
- MSK: Normal extremities & spine.
- NEURO: Normal muscle strength and tone. No focal deficits.
GROWTH CHART: Following growth curve well in all parameters.
ASSESSMENT/PLAN:
* Healthy _-month old toddler
- The family was given a children’s book today (per “Reach Out and Read” program).
- The family was given a list of dentists in the county who take MediCal.
- CBC and lead level ordered.
- Follow up at 18 months of age, or sooner PRN.
- ER/return precautions discussed.
* Vaccines today:
- DTaP #4, Influenza
- Pentacel #4 (DTaP, IPV, Hib), Influenza
* Anticipatory guidance (discussed or covered in a handout given to the family)
- Common immunization SE’s
- Safety: Child-proofed home, burn prevention, kitchen safety, water safety, firearms, sunscreen, Poison Control number (800-222-1222)
- Car seat facing backward until 2 year of age and 20 pounds
- Dental care and fluoride; dental visits
- Food: Picky eating, fortified whole milk, limiting juice and junk/fast food.
- Transitioning from bottle to cups; no bottle in bed
- Discipline: Praising wanted behaviors, distraction, setting limits, routines.
- Emerging independence (offer choices)
- Speech development (importance of reading and talking)
- Sleep: Nightmares, sleep hygiene
- Limiting screen time
- Hazards of second hand smoke