Well Child Check: 9 month old

9 MONTHS

SUBJECTIVE:

9 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 a regular bedtime routine, and sleeps through the night without feeding.

- Behavior: No concerns.

PM/SH:

Normal pregnancy and delivery. No surgeries, hospitalizations, or serious illnesses to date.

DEVELOPMENT:

- Gross motor: Sits well on own, crawls, cruises, pulls self to stand (with help)

- Fine motor: Uses pincer grasp, takes finger foods.

- Cognitive: +object permanence, likes to look at books.

- Social/Emotional: Laughs, likes to play games (e.g. “peek-a-boo”), early signs of stranger anxiety, seeks parents for comfort.

- Communication: Understands a few words, babbles, imitates sounds, says nonspecific syllables (“mama,” “dada”), points out objects.

SOCIAL:

- No smokers in the home.

- No concerns regarding postpartum depression.

- 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. Anterior fontanelle _

- EYES: Red reflex present bilaterally. Light reflex symmetric. EOMI, with no strabismus.

- ENMT: TMs, nares, and OP normal. MMM. No abnormal oral lesions.

- NECK: Supple, with no masses.

- CV: RRR, no m/r/g. Normal femoral pulses.

- 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. No hip clicks or clunks.

- NEURO: MAE symmetrically. Normal muscle strength and tone.

GROWTH CHART: Following growth curve nicely in all parameters.

ASSESSMENT/PLAN:

* Healthy 9-month old infant

- The family was given a children’s book today (per “Reach Out and Read” program)

- Follow up at 12 months of age, or sooner PRN.

- ER/return precautions discussed.

* Vaccines today:

- Influenza

- None

* Anticipatory guidance (discussed or covered in a handout given to the family)

- Avoiding use of walkers and door swings/jumpers.

- Child proofing the home: Gates for stairs, burn prevention, kitchen safety, water safety

- Poison Control number (800-222-1222)

- Car seat facing backward until 2 years of age and 20 pounds

- Dental care and fluoride (first tooth at 3-12 months, average 7 months)

- Food: Iron-fortified foods, no honey/corn syrup/cow’s milk until one year old, finger foods, no/minimal juice

- Choking hazards

- No juice from bottle; no bottle in bed; introducing a sippy cup

- Speech development (importance of reading and talking)

- Sleep: Separation anxiety, night awakening, sleep training, lower crib mattress, side rales up