Office Visit Note
Narrative: PATIENT: Greta Morrison (referred to as 'unknown infant' in dictation) CHIEF COMPLAINT 9-month well child visit with concern about a spot on the back and earwax HISTORY OF PRESENT ILLNESS Parents bring in their 9-month-old daughter for a well child visit. She is doing well overall. Parents note a small spot on her back noticed a couple of days ago, described as rough and scab-like. They also note a new spot on her nose that appeared recently. Dad asks about earwax in her ears. She is breastfeeding and eating solids once to twice daily, including mashed foods such as meatballs, beef, and peas. Parents ask whether she should be having 3 meals a day. She has 8 front teeth. Mom is reported to be sore from breastfeeding/teething. Parents are giving vitamin D drops, though they occasionally miss doses. Developmentally, she is crawling fast, sitting well, pulling to stand on furniture and walls, briefly free-standing, and attempting steps before falling. She is in a favorites/stranger awareness phase. She puts everything in her mouth. REVIEW OF SYSTEMS Skin: Rough, scab-like spot on back for a couple of days; new spot on nose noticed recently. Ears: Earwax noted by parents. Feeding: Eating solids once to twice daily in addition to breastfeeding; tolerating a variety of mashed table foods. Dental: 8 front teeth erupted; no current teething pain. Development: Crawling, pulling to stand, briefly free-standing, attempting steps. Denies concerns about pain, fever, or illness. MEDICATIONS REVIEWED Vitamin D drops – currently taking, occasional missed doses. Parents counseled to continue. PHYSICAL EXAM General: Well-appearing, alert, interactive, happy infant. Social and engaged beyond stated age. Skin: Small dry, rough patch on the back consistent with eczema/dry skin. Small spot noted on nose. No concerning features. Ears: Earwax present; tympanic membranes visualized, normal. Cardiovascular: Normal heart sounds, no murmur. Lungs: Clear to auscultation. Musculoskeletal/Neurologic: Sitting independently with good stability. Motor skills advanced for age. ASSESSMENT 1. 9-month well child visit – growth and development appropriate; motor and social skills advanced for age. 2. Small dry skin spot on back – consistent with eczema or dry skin; not concerning. 3. New spot on nose – likely transient; no concerning features at this time. 4. Earwax – present, ears otherwise normal. 5. Hepatitis B vaccine series – not yet started; discussed plan to initiate. 6. Feeding and nutrition counseling – transitioning to increased solid food intake. PLAN 1. Well child visit: Growth parameters reviewed (weight 16 lbs 8 oz, length 27 inches). Development is advanced with crawling, pulling to stand, free-standing briefly, and attempting steps. No vaccines administered today. Hepatitis B series has not been started; parents counseled this is not urgent but should be initiated before daycare/preschool entry. A nurse visit can be scheduled in the next month or two for the first dose. MMR vaccine discussed as a priority at the 12-month visit. 2. Dry skin/eczema on back: Reassured parents this appears to be a benign dry skin spot. No treatment recommended at this time; monitor for changes. 3. New spot on nose: Likely transient given infant skin. Parents counseled to monitor for growth, color change, or if it becomes bothersome, and to report any changes. 4. Earwax: Ears examined and appear normal. Parents counseled not to insert anything into the ear canals. May gently wipe visible wax from the external canal with a tissue. 5. Feeding: Parents reassured that at 9 months, 2-3 meals of solids daily is appropriate in addition to breastfeeding. Emphasized importance of adequate iron intake. Discussed choking risks — food should be fingertip-sized or smaller; choking risk persists through kindergarten age. Continue breastfeeding as desired. 6. Vitamin D drops: Continue daily; encouraged consistency. FOLLOW-UP Follow up at 12-month well child visit; MMR vaccine at that time. Nurse visit in 1-2 months for Hepatitis B vaccine initiation. Call sooner if any concerns arise. ANTICIPATORY GUIDANCE Safety counseling provided: with increased mobility (crawling, pulling to stand), the home should have a safe place to put baby down (crib, pack and play) when supervision is not possible. Discussed mouthing behavior and keeping small objects out of reach. Sun safety discussed — apply sunscreen to all exposed areas, use protective clothing and hats given high burn risk. Stranger anxiety/favorites phase is developmentally normal; parents counseled to use calm, reassuring energy when separating. Teething: next molars typically expected around 12 months; may get a brief reprieve from teething discomfort. ICD-10 CODES Z00.121 - Encounter for routine child health examination with abnormal findings L30.9 - Dermatitis, unspecified (dry skin/eczema spot on back) CPT CODES 99391 - Preventive visit, established patient, infant (age under 1 year) ───────────────────────────────────────── CODES: CPT 99391 | ICD-10 Z00.121, L30.9 Source: Cloud iOS recording (2026-06-06T15:37), backfilled from device 2026-08-23; identity verified from visit transcript