Well Child Check: 9 month old
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.
Normal pregnancy and delivery. No surgeries, hospitalizations, or serious illnesses to date.
- 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.
- 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.
- Up to date.
- 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.
* 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:
* 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