Well Child Check: 15 month old

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