Office Visit Note
Narrative: CHIEF COMPLAINT 6-month well child visit; parent also reports ongoing congestion/possible reflux and asks about earwax HISTORY OF PRESENT ILLNESS Cooper is a 6-month-old female presenting for her well child visit. She is fed Bobbi formula, which has not been changed. Solids were introduced starting with applesauce, which seemed to cause constipation. After a one-week break from solids, parents reintroduced foods using allergen-containing pouches (Grow Happy brand) mixed into yogurt or banana. She is now eating a wide variety of table foods including steak and foods the family eats at restaurants. Constipation resolved after discontinuing applesauce. She started crawling (army crawl) a couple of weeks ago and is mobile throughout the home. Stranger awareness has emerged. She is babbling with consonant sounds. Sleep is described as "pretty good" — she has recently begun sleeping through the night intermittently, approximately 10–11 hours (e.g., 7 PM to 6 AM last night). She takes two naps daily, each approximately 45 minutes. She had previously dropped to one afternoon nap but has returned to two. Parents have not been aggressive with sleep training; when she wakes genuinely upset at night they have fed her, though they are now working to shift more calories to daytime. Parent would prefer she sleep a bit longer in the morning. Mother reports Cooper has had fairly persistent nasal congestion and notes she can sound congested at times. Some of this may be related to a recent cold, and parent wonders whether some component could be reflux. Parent also asks about visible earwax. The family is planning travel to Copenhagen and Stockholm at the end of June for approximately one week. Measles risk was discussed. REVIEW OF SYSTEMS Congestion: positive, described as persistent/recurrent. Possible reflux symptoms noted by parent. Constipation: resolved after discontinuing applesauce. No fevers or other acute concerns reported. Sleep: sleeping 10–11 hours at night with intermittent nighttime awakenings, two daytime naps. Development: crawling (army crawl), babbling with consonant sounds, stranger awareness emerging. PHYSICAL EXAM General: Well-appearing, sweaty, alert infant. Appropriate stranger awareness noted during exam. Weight: 18.5 lbs HEENT: Earwax visible bilaterally but tympanic membranes visible through wax. Head shape normal. Musculoskeletal/Neurologic: Good strength. Age-appropriate motor development; army crawling observed. Development: Crawling (army crawl), babbling with consonant sounds ("aba"), appropriate stranger anxiety. Development described as fabulous. ASSESSMENT 1. Well child visit, 6 months — growth, development, and exam are reassuring. Weight 18.5 lbs. 2. Nasal congestion, persistent — possibly related to recent upper respiratory infection; parent also raises concern for possible reflux component. 3. Earwax — visible but not obstructing visualization of tympanic membranes. 4. Constipation, resolved — occurred with introduction of applesauce, resolved after discontinuation. 5. Immunizations due — Prevnar (third of four) and Pentacel (third of four). 6. International travel counseling — upcoming trip to Scandinavia, measles risk discussed. PLAN 1. Well child: Growth and development are excellent. No concerns identified. Continue Bobbi formula. Continue offering a variety of table foods and allergen introduction as family has been doing. Encouraged family feeding at shared meals. 2. Congestion/possible reflux: As Cooper becomes more upright with developmental progression, congestion may improve. Will monitor. No intervention at this time. 3. Earwax: Reassured parents that earwax is not obstructing and tympanic membranes are visible. Advised against digging or instrumentation at home. 4. Constipation: Resolved with discontinuation of applesauce. No treatment needed. 5. Immunizations: Prevnar and Pentacel administered today (both third doses in series). Vaccines given in bilateral thighs. 6. Travel: Discussed measles risk with international travel to Copenhagen and Stockholm at end of June. Reviewed current epidemiologic data — Finland, Sweden, Norway, Denmark, and Iceland have low to zero measles cases; risk is concentrated more in mainland Europe. After review, early MMR vaccine was not recommended at this time. Family reassured. FOLLOW-UP Routine well child visit at 9 months. ANTICIPATORY GUIDANCE Choking safety discussed in detail: recommended fingertip-sized pieces of food that can be swallowed whole without mashing as a test for readiness; advised shredded proteins, overcooked vegetables, and overcooked pasta as safer options. Emphasized choking as a significant safety concern at this age. Sleep and behavior guidance: Discussed the developmental transition at 6 months toward parent-directed scheduling. Encouraged consistent routine and setting limits. Discussed that infant is learning that her behavior impacts the world and may test boundaries with vocalizations and behavior. Reassured that it is appropriate to allow brief periods of fussiness and to maintain parental structure around sleep, feeding, and daytime schedule. Encouraged shifting calories to daytime to support sleeping through the night. ICD-10 CODES Z00.121 - Encounter for routine child health examination with abnormal findings J00 - Acute nasopharyngitis (common cold) / nasal congestion CPT CODES 99391 - Preventive medicine, established patient, infant (age under 1 year) ───────────────────────────────────────── CODES: CPT 99391 | ICD-10 Z00.121, J00 Source: Cloud iOS recording (2026-05-28T18:01), backfilled from device 2026-08-23