REASON FOR VISIT: The patient is now a 1-year-old. He is here for his yearly physical or 12-month check.
INTERVAL HISTORY: The patient did well in the past 3 months. He was here one time because of an upper respiratory tract infection. He did not have an ear infection.
FAMILY SITUATION: The patient’s family just moved to a bigger house this fall. He goes to daycare 4 times a week.
NUTRITION: He eats well according to his mother. He eats people food now. Now that he has tasted people food, he does not like baby food anymore. Mom is still nursing him. He is not using the bottle anymore. He will be started on whole milk.
ELIMINATION: His bowel movements are every day. No problems. He is also voiding well.
SLEEP: Bedtime is about 8:30 to 9:30 at night and he wakes up at 6:30 or 7:30 in the morning. He sleeps through the night now, except for the past few nights that he has been waking and mom thinks that this is because of his teething.
BEHAVIOR: He is described as playful according to his mother.
DEVELOPMENT: He has about 6-8 words now.
FINE MOTOR SKILLS: He picks up very small things. He manipulates his toys.
GROSS MOTOR SKILLS: He holds very well. He holds up to stand and stands without holding anything for a few minutes. He walks with support but is not walking without support yet. He cruises around furniture at home.
SOCIAL DEVELOPMENT: He throws kisses. He waves bye-bye. He points at objects. He looks at where you are pointing up.
REVIEW OF OTHER CONCERNS: The patient had blood and hematocrit done at 8 months of age. His hematocrit was slightly low. He was started on Poly-Vi-Sol with Iron. He is still getting that multivitamin with iron, except for the past several days. Mom has lost it during the move. She will buy another one to start giving him again.
CONCERNS: None.
PHYSICAL EXAMINATION: The patient is an alert, active, small 1-year-old boy. Height is 29 inches, 5-10th percentile. He was on 25th percentile at 6 months and gradually has gone down to 5-10th percentile. Weight is 18 pounds 10 ounces, 5-10th percentile. Head circumference is 17-1/2, 10th percentile. HEENT: Anterior fontanelle is now closed. Both tympanic membranes are clear without any evidence of fluid behind. Both conjunctivae are clear. Pupils are equal and reactive to light. Red-orange reflexes are positive in both eyes. Nose is clear. Mouth is clear. He is teething. The right upper canines are just starting to erupt. The lateral lower incisors are just coming in. There is no neck mass. Neck is supple. Chest and lungs are symmetric. Good air entry. Clear breath sounds. Heart: Normal first and second heart sounds, regular rhythm, no murmurs. Abdomen: Soft, not distended. No hepatosplenomegaly. No tenderness. External Genitalia: Both testes are descended. No scrotal mass. Skin is normal. Extremities: Femoral pulses are easily palpable. Hips are stable. No Galeazzi sign. No MTA deformity. Skin: Clear. Neurologic: Exam normal.
ASSESSMENT: The patient is a well 1-year-old boy. There is some slowdown in both height and weight. He is teething, but otherwise is fine.
PLAN: We discussed his nutrition. I would give him whole milk now by the cup. We discussed his sleep behavior and development and injury prevention. For his immunizations, he will get varicella #1, hepatitis A #1, and PCV7 #4 today. Mom will continue to give him his multivitamins with iron. His next checkup is at 15 months of age. Mom answered the PEDS Response Form and did not have any concerns.
