Office Visit Note
ElationNoteColOne: wt 14.4 ElationNoteColOne: 2 teeth ElationNoteColOne: growing and dev great ElationNoteColOne: breast feeding with vitd ElationNoteColOne: headed to AZ for a month next week ElationNoteColOne: given amox/zmax/zofran to travel with ElationNoteColOne: given bebird ElationNoteColTwo: HPI: Hpi: * Teething: * Two bottom teeth erupted; intermittent chewing pain * Nursing going okay; had a brief bite once * No expectation for upper teeth soon per discussion * At ~4.5 months, two erupted bottom teeth * Intermittent recurrence of chewing pain with periods of improvement * Nursing going well; one bite incident * Two bottom teeth have erupted * Intermittent chewing pain with brief improvement then recurrence * Concern about timing of upper teeth; advised they may not be soon Hpi: * Development: * Rolling front-to-back and back-to-front * Picking objects up; strong motor skills * Social engagement high * Sleeps well: 8:30 pm–6:00 am with returns to sleep; naps ~9 am, noon, 3 pm for ~1 hour each * Rolling front-to-back and back-to-front * Picking objects up * Strong gross and fine motor skills * Excellent social skills * Very attached to primary daytime caregiver (dad) * Rolling front-to-back and back-to-front * Strong gross and fine motor skills * Socially interactive and attached to primary daytime caregiver (dad) Hpi: * Safety: * Fell/jumped out of a bouncer when one leg strap was not buckled * Cried, no reported sequelae * Fell from a bouncer chair when only one leg strap was buckled; cried but was fine afterward Hpi: * Feeding interest: * Shows significant interest in parents’ foods * Previously tried a small taste of squash soup and liked it * Currently primarily breastfeeding; receiving vitamin D; occasional bottle of pumped milk * Primarily breastfeeding; receiving vitamin D * Strong interest in solid foods; small taste of squash soup and liked it Hpi: * Travel plans: * Flying next Saturday; will be away until ~February 20th to Arizona (base in Show Low) * Seeking advice on introducing solids and travel medications * Flying next Saturday to rural Arizona (Show Low) until ~Feb 20 * Discussed illness preparedness and contact options * Flying next Saturday, returning ~Feb 20 * Plan to delay starting solids until back * Will be in rural Arizona (home base in Show Low) ElationNoteColTwo: Data: Data: * Growth discussed; weight tracking around 25th percentile per clinician’s review of growth chart (weight 14.4 lbs entered). ElationNoteColTwo: Reconciled Medications: Med: * Vitamin D (dose/frequency not specified) ElationNoteColTwo: Family History: Family: * Mother reportedly produces excessive earwax ElationNoteColTwo: Social History: Social: * Lives with mom (Maddie) and caregiver father (primary daytime caregiver). Strong family support; maternal grandfather visiting; paternal grandmother visiting. Recent swimming class attempt; infant cried throughout. Social: * Lives with parents; dad is primary daytime caregiver while mom works from home. Strong family support with visits from grandparents. Upcoming extended stay in an Airbnb in rural Show Low, Arizona for work. Social: * Lives with parents; dad is primary daytime caregiver while mom works from home. Strong family involvement (grandparents visiting/helping). Upcoming extended travel to Arizona; access to virtual care with current clinician. ElationNoteColTwo: Vitals: Data: - Blood Pressure: / - Weight (lbs): 14.4 ElationNoteColTwo: PE: PE: - General: Alert, interactive, acting like an older kid Well-appearing infant; interactive and developmentally advanced behaviors for age. Well-appearing infant, alert, interactive. - Eyes: Normal - HENT: Normal Two erupted lower incisors. Parent notes increased earwax. No abnormal ear findings documented. Two lower teeth visible. Increased earwax reported by caregiver. - Neck: Normal - Resp: Normal respiratory effort and breath sounds; no distress Normal respiratory effort; no abnormal respiratory symptoms. No respiratory distress; normal by implication. - CVS: Normal No concerns; normal by history and observation. Normal by implication. - Breast: Normal - Abdom: Normal - GU: Normal - MSS: Strong motor tone/skills observed - NS: Normal Normal gross and fine motor behaviors; strong tone and strength observed. Age-appropriate gross and fine motor skills; socially engaged. - Skin: Normal No issues reported. - Lymph: Normal - Psych: Social skills amazing; bonded/attached to primary caregiver Socially engaged; appropriate affect and interaction. - Pelvic: Normal - Rectal: Normal ElationNoteColTwo: Assessment & Plan: Assessplan: * Teething discomfort: Assessplan: * Introduction of solids: Assessplan: * Development: Assessplan: * Safety counseling: Assessplan: * Travel preparation: ElationNoteColTwo: Follow Up: Followup: Check in after return (~after Feb 20) to schedule and receive shots. Notify clinician upon landing with location for assistance identifying nearby clinicians if needed. Call/text anytime during travel if issues arise. Check in when you return from Arizona to receive scheduled immunizations. Notify clinician when you land with your location for local clinician identification if needed. Contact anytime during travel for guidance before using any provided medication. Check in after you return (after ~Feb 20) to proceed with scheduled vaccinations. Contact me when you land with your location; I will identify nearby clinicians if needed. Call/text anytime during travel if concerns arise; virtual visit available.