Well child – 9 mo

Sep 21, 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
Elimination:

no concerns

GROWTH:

chart provided, reviewed, developing well
MILESTONES:

sits, pulls to stand walks peekaboo, looks at pictures, pokes w finger, shakes-bangs-throws-drops objects, feeds self with fingers responds to name, understands some words, imitates sounds, babbles stranger anxiety, seeks parent for comfort

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

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, ocular alignment appears normal
Ears:

appears to hear normal canals & TMs
Nose:

nares patent
Mouth:

oral mucosa moist & without lesions teeth present
Throat:

w/o swelling or exudates
Neck:

supple, symmetrical ROM
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
Genitalia:

normal appearance uncircumcised circumcised testes down bilaterally
Musculoskeletal:

symmetrical FROM, 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:

safety, childproof home, avoid walkers, poisons age-appropriate discipline, consistent routine, limit but enforce rules, distraction as discipline drinking from cup, self-feeding, avoid choke foods, food variety, brush teeth

FOLLOW UP:

12 months of age, sooner if concerns arise

Well child – 9 mo

Result - Copy and paste this output: