6 Mo pt, the product of a SVD @ term comes in for WCC. Pt on schedule with vaccinations.
Eating pureed foods three times per day,
Drinking 7 oz of infamil q 3hrs;
BMs 2-3 per day
Voids more than 5 times per day. No incidences of diaper rashes.Sleep: Sleeps all night
Developmentally, patient says dada & baba; sits up without support, grabs things, picks objects, is beginning to crawl, recognizes mom, seems happy.
Behaviorally, Patient is consolable when he cries.
Patient has one brother at home. Is taken care of at home and doesn’t go to day care. Grand parents live at home and help with care. Mum doesn’t feel stressed.
ROS is negative.
Physical Examination
Head Circumference = __% ; Wt = ___ %; Ht = __ %. NB % = percentile
General: Patient is alert and playful.
HEENT
Head – NC/AT; Posterior fontanel closed, AF is flat
Eyes – PERRL, red reflex present. (Note infants may not be able to accomodate)
Ears – TMs normal
Nose – Normal mucous membranes, no rhinorhea
Throat & Mouth – Sucking and rooting reflex present, palate normal.
Neck – Supple
Lungs – CTA
Heart – RRR, no murmurs
Abd – Normal BS, no tenderness, umbilicus healed.
Genital area:Both testicles palpated in scrotum, no diaper rash present.
Back – No excessive hairs or abnormality in the sacral area
Hips: Ortolani and Barlow negative.
A/P
7 mo old healthy male, the product of term SVD with adequate prenatal and postnatal care. No prenatal, perinatal or postnatal complications. No past medical problems. Has been uptodate with immunizations. Mom is not depressed and has adequate support at home to care for the baby.
Anticipatory guidance discussed. Education on child safety provided. Counseling provided on nutrition and food introduction done. Patient will call clinic or go to ED if child becomes sick or if she has concerns.
Immunizations given today:
Patient will get:
Pentacel #3
Heb B #3
PCV #3
Rota #3
Follow up in 3 months for 9 month well child check.
This patient was seen and presented to attending physician, ______ who agrees with this plan.