Relevant Demographic Data
C.N. is a 15-month healthy-looking African-American female brought to the clinic for a routine 15-month well-child visit. She has been visiting this clinic for her well-child checkups and other medical appointments since birth. The patient resides with both parents, who are present in this session. C.N has an older sibling aged 3 who is currently in preschool. Both her caregivers are attentive to her during this appointment and are effectively responding to queries about her developmental progress.
Subjective
The patient’s mother reports that C.N feeds well and denies her being selective about foods. She states that the child consumes between 16 to 24 ounces of whole milk daily using a cup and can feed herself various foods, including fruits and vegetables, without a fuss. The patient’s parents report that she sleeps in her own bed from 7:30 pm to 7 am. C.N does not use a pacifier or feeding bottle during her sleep time. The patient’s father states that the child rarely uses a pacifier, even during the day. C.N’s mother reports she gets her teeth brushed twice on a daily basis. In addition, she explains that the patient is looked after by a babysitter from Monday to Friday and reacts well to new environments and situations. The mother denies that the babysitter has reported any concerns. Both caregivers deny any problems during this visit, and both concur that her development has been on track since her last well-child checkup at 12 months.
History of Present Illness
The patient denies any presence of current illness.
Relevant Past Medical History
Regarding the patient’s medical history, there are no reports of any major illnesses in her past. Her records indicate that immunizations are up-to-date for her age, including Hepatitis B (Hep B), Diptheria, tetanus and whooping cough (Dtap), Haemophilus influenza type b (Hib), polio (IPV), and Pneumococcal disease (PCV). The patient has also received her first dose of Varicella and Measles, mumps, and rubella (MMR) but is due for her first Hepatitis A (Hep A) vaccine today. She is yet to get the annual influenza vaccine, and her parents agree to follow up later.
Relevant Past Surgical History
The patient denies any history of surgery.
Relevant Family Health History
The patient’s parents are both alive and healthy, with the mother and father aged 30 and 33 years, respectively; however, their medical history remains unknown. There is a significant history of cardiovascular and diabetes on the maternal side. In this case, the maternal grandmother, aged 77, was diagnosed with hypercholesterolemia about 5 years ago. Conversely, the paternal side has had a record of asthma and cancer, with the paternal grandfather, aged 83, living with prostate cancer.
Current Medications
The patient denies any current medication use.
Relevant Diagnostic Findings
No screenings were made since the patient did not present any health concerns. The anemia screening had been conducted during the previous well-child checkup at 12 months and showed no concerns, while the developmental surveillance is scheduled at the 18-month well-child visit.
Review of Systems
Based on the general appearance, this is a well-developed, alert, interactive, and healthy African-American female who seems to be in no acute distress. There is no dryness, itching, rashes, edema, abnormal skin color, or lesion on the skin. Additionally, the head is negative for bruises, with the eyes showing no visual loss, swelling, itching, or discharge. Similarly, there is no hearing loss, pain, or discharge in the eyes, with the nose negative for sinus pain, nasal congestion, or discharge. In addition, no mouth ulcers, sore throat, or problems with swallowing. The neck is negative for swelling, pain, stiffness, or enlarged lymph nodes. Equally important, the respiratory system is negative for cough, tachypnea, or wheezing, and neither is there erythema of the skin or cyanosis in the cardiovascular structure. There is no vomiting, diarrhea, abdominal pain, constipation, or nausea; no vaginal discharge or blood in the urine. The musculoskeletal and psychiatric are negative for weakness or agitation, respectively. Moreover, there are no tremors, unsteady gait, weakness, paralysis, or loss of consciousness; no excessive hunger, sweating, or thirst.
Objective
Vitals
Temperature 97.7 ˚F (oral), Respiration 24 breaths/minute, Pulse 120 beats per minute, Blood Pressure 97/67, height 77centimeters (30.5 inches), weight 10.5kilograms (22 lbs).
Physical Exam Findings
Generally, the patient appears well-groomed, adequately nourished, and shows no distress. The head is normocephalic with no signs of bruises; eyes: pupils equal, round and reactive to light, extraocular movements, sclera white, and no discharge or hemorrhage noted. In the ears, the tympanic membranes and external auditory canals are clear; nose: normal pink mucosa, no discharge or polyps. The mouth has eight teeth without cavities with the buccal mucosa moist; throat: pharynx with no signs of ulceration or erythema. In addition, the neck is supple, has a full range of motion (ROM), and has no lymphadenopathy.
The lungs sound bilaterally clear, with no wheezing or rhonchi. The heart has a regular rate and rhythm with no murmurs; gastrointestinal: soft abdomen, non-distended, no tenderness, positive bowel sounds in all four quadrants, and no masses noted. The skin is intact, warm, and dry, with no bruises, rashes, or lesions. Neurologic: alert with no focal deficit; extremities: full ROM, no clubbing, cyanosis, or edema. The back is straight with no scoliosis; musculoskeletal: symmetrical, full ROM, no joint swelling, kyphosis, or lordosis. Integumentary: No rashes, lesions, lacerations, wounds, or excessive dryness.
Assessment
Differential Diagnosis
There was no differential diagnosis because this was a well-child checkup.
Actual Diagnosis
Routine well-child check V20.2. The diagnosis was based on physical examination findings.
As at this well-check appointment, the patient’s development is in line with her age. The child is healthy, and all the body systems are working appropriately. Following the physical examinations, no major health problems were detected. The child has effective motor skills, and her language is developing as expected for her age. She is interactive and able to complete age-specific tasks, including uttering a few words, such as “No,” which is common for children her age (Centers for Disease Control and Prevention, 2022a). The medical assessment shows that patient is 15 month female with normal growth and development. Nevertheless, the child can benefit from more social interactions with peers and family. In addition, the patient can use more practice with self-feeding exercises. Dental appointments on a yearly basis are recommended for the child. Anticipatory guidance on safety, behavioral and developmental milestones will be provided to the parents.
Plan
There are no ordered diagnostics, medications, or referrals because this is a routine well-child visit. The child is healthy, and her growth is within the appropriate percentiles; she will get her Hep A vaccine today. The parents were educated on ensuring the child’s safety by keeping guns, cleaners, and medications out of reach to create a conducive environment for her to explore (Fuzzell et al., 2018). In addition, emphasis was made on injury prevention by ensuring car safety, water/ swimming safety, and applying sunscreen on the child’s skin during outdoor activities to prevent sunburns.
There is a need for more practice on the child’s self-feeding exercise, particularly using a fork and spoon to enable her to learn such skills at an early age. Parents need to interact more with the child by talking, singing, reading, and playing to improve her language skills (Snijders et al., 2020). They also need to limit the screen time for the child to less than an hour a day to allow her to improve her social skills and learn from the environment (Turner, 2018). Having a regular sleeping routine is also fundamental for the child’s development.
Parents were guided on the importance of providing a well-balanced diet for the child, including milk, proteins, vegetables, and fruits, to boost her development. Emphasis was made on avoiding sugary drinks and encouraging adequate water intake (American Academy of Pediatrics, 2022). Brushing twice a day was recommended for the child, and yearly dental appointments (Centers for Disease Control and Prevention, 2022b). The caregivers were also advised on the need to praise the child for good behavior and use time-outs to correct bad habits.
Caregivers were educated on the child’s reaction to the Hep A vaccine at the injection site, such as swelling, tenderness, and signs of fever lasting between one to two days. All parents’ questions regarding their child’s development were effectively addressed. In addition, anticipatory guidance for the next three months until the 18 months visit was discussed. The parents have received an educational handout for vaccines and expected 15-month development. A follow-up appointment is to be scheduled for the 18-month well-child visit, and caregivers are asked to return for the annual influenza vaccine. The parents expressed their understanding and concur with the plan of care.
References
American Academy of Pediatrics. (2022). Bright futures information for parents: 15 month visit. Web.
Centers for Disease Control and Prevention. (2022a). Important milestones: Your baby by fifteen months. Web.
Centers for Disease Control and Prevention. (2022b). Children’s dental health. Web.
Fuzzell, L. N., LaJoie, A. S., Smith, K. T., Philpott, S. E., Jones, K. M., & Politi, M. C. (2018). Parents’ adherence to pediatric health and safety guidelines: Importance of patient-provider relationships. Patient Education and Counseling, 101(9), 1570–1576. Web.
Snijders, V. E., Bogicevic, L., Verhoeven, M., & van Baar, A. L. (2020). Toddlers’ language development: The gradual effect of gestational age, attention capacities, and maternal sensitivity. International Journal of Environmental Research and Public Health, 17(21), 7926. Web.
Turner, K. (2018). Well-child visits for infants and young children. American Family Physician, 98(6), 347-353. Web.