Well child – 6 mo

Sep 20, 2018 • Mark Morgan

categories: Pediatrics

HISTORY:

provided by parent provided by other unobtainable d/t parental anxiety and/or lack of knowledge interpretation provided by family member interpretation provided by MA
SPECIAL NEEDS:

none specialty
SOCIAL HISTORY:

no changes child care housing single parent working parent siblings

REVIEW OF SYSTEMS
Interval change:

doing well, no changes since last visit no illnesses or injuries no specific concerns raised no visits to health care providers, facilities questionnaire provided & reviewed
Nutrition:

no concerns breast formula solids
Urination:

no concerns
Stooling:

no concerns
Sleep:

no concerns

GROWTH:

chart provided, reviewed, developing well
MILESTONES:

rolls over, no head lag when pulled to sit, sits w support, bears wt when placed grasps and mouths objects, transfers cubes from hand to hand, rakes in small objects string of vowels (ah, eh, oh), says dada/mama, turns to sounds, recognizes own name, babbles reciprocally smiles, laughs, squeals, shows recognition & pleasure from interactions with parents or others, self-comforts

=========================================

Appearance:

well-appearing active, interactive no distress uncooperative with exam
Skin:

pink, normal turgor no rashes no bruises
Head:

no skull deformities plagiocephaly
Eyes:

red reflex bil, appears to see, ocular alignment appears normal
Ears:

appears to hear normal canals & TMs
Nose:

nares patent
Mouth:

oral mucosa moist & without lesions bottom central incisor(s) present
Throat:

patent pharynx w/o swelling or exudates
Neck:

supple, symmetrical ROM, turns head side to side
Chest:

unlabored respirations, symmetric chest expansion, clear and equal breath sounds bilaterally
Heart:

regular rate & rhythm, no murmurs
Abdomen:

soft, nondistended, nontender, no obvious palpable masses, bowel sounds normal
Genitalia:

normal appearance uncircumcised circumcised testes down bilaterally
Extremities:

symmetrical FROM w/o clicks
Back:

normal spine
Neuro:

normal reflexes, normal & symmetrical tone/strength

===========================================

LABORATORY/OFFICE DIAGNOSTICS:

none normal pending

IMMUNIZATION:

per schedule deferred declined

OUTSIDE ORDERS/REFERRALS:

none laboratory studies diagnostic studies specialty WIC

DISCUSSED AND/OR HANDOUT GIVEN/OFFERED:

exam findings & recommendations diagnostic studies development &growth smoke-free environment, sun exposure, falls, no infant walkers kitchen safety & poisons, hot liquids begin/continue cup & solids foods, choking, brush teeth, no bottle in bed talk, sing, read, play music, exploration opportunities, distraction as discipline, enforce rules, sibling & others interaction

FOLLOW UP:

9 months of age, sooner if concerns arise

Well child – 6 mo

Result - Copy and paste this output: