Well child – 15 mo

Sep 24, 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 bottle cup milk less 16 oz
Elimination:

no concerns
Behavior:

no concerns

GROWTH:

chart provided, reviewed, developing well
MILESTONES:

bends w/o falling, walks well, climbs stairs, puts blocks in cup feeds self w fingers, drinks from cup imitates parents, helps in house 2-4 words, tells wants by pointing-grunting-pulling, points to body part, brings toys to show, follows simple commands, scribbles

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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
ENT:

normal canals & TMs, normal external nose, teeth present, no caries, op w/o swelling or exudates
Neck:

supple, no LAD
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

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IMMUNIZATION:

per schedule deferred declined

OUTSIDE ORDERS/REFERRALS:

none laboratory studies diagnostic studies specialty WIC

DISCUSSED AND/OR HANDOUT GIVEN/OFFERED:

home safety, bike helmet, healthy oral habits, no bottle, limit sugar give limited choices, distraction, praise, temper tantrums, hitting-biting-aggression, consistent routines, read & talk w child

FOLLOW UP:

18 months of age, sooner if concerns arise

Well child – 15 mo

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