Well child – 18 mo

Sep 26, 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 milk less 16 oz
Elimination:

no concerns
Behavior:

no concerns

GROWTH:

chart provided, reviewed, developing well
MILESTONES:

walks up steps, throws ball, uses spoon & cup without spilling, stacks 2 small blocks speaks 6 words, uses two-word phrases, points to 1 body part, follows simple directions laughs in response to others, shows affection listens to story, looks at pictures & names objects
DEVELOPMENTAL SCREEN (ASQ):

declined take home scored normal
AUTISM SCREEN (M-CHAT):

declined take home scored normal

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

Appearance:

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

pink, normal turgor no rashes no bruises
Head:

no skull deformities plagiocephaly
Eyes:

EOM intact, ocular alignment appears normal
ENT:

normal canals & TMs, normal external nose, no dental decay, 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:

no gross deformities, normal spine
Neuro:

normal gait & coordination

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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:

safety, read-talk-sing, reinforce limits, feelings and emotions, listen-respect-interest in activities, toilet training, healthy food choices, dental visit, hitting-biting-aggressive behavior

FOLLOW UP:

24 months of age, sooner if concerns arise

Well child – 18 mo

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