Office Visit Note
Narrative: CHIEF COMPLAINT 12-month well-child visit with parental concern about delayed walking HISTORY OF PRESENT ILLNESS Tommy is a 12-month-old male presenting for his well-child visit. Mother's primary concern is that he is not yet walking independently. He crawls well, doing both army crawling and crawling on all fours. He uses a sit-in walker and moves very fast in it. He does not frequently pull himself up to standing. Mother attributes some of the delay to their busy lifestyle with older siblings in hockey, noting he spends significant time in car seats and strollers. She has recently been intentional about giving him more floor time, after which he picked up crawling quickly. She is motivated to encourage walking as he is supposed to walk in a wedding at the end of April. She asks what she can do to encourage walking. No other developmental concerns - he has good communication with several words including mama, dada, and hi. He points frequently. Family history notable for older siblings walking at 13 months and 15-16 months respectively. REVIEW OF SYSTEMS Constitutional: No fever, feeling well. GI: Mother notes stomach bugs going around at school, asking about incubation period. No current GI symptoms in patient. Development: Speaking several words, good communication, pointing. Gross motor delay as noted in HPI. PHYSICAL EXAM Weight: 22 lbs 2 oz. Length: 30.75 inches. Growth parameters approximately 50th percentile - described as 'about as average as you get.' General: Well-appearing, interactive toddler. Alert and engaged during exam. Musculoskeletal: **Hips noted to be 'a little open' on exam.** Mother reports W-sitting posture. Skin: Early freckles noted. Developmental: Uses several words (mama, dada, hi), points, follows commands, interactive. Walks with support in sit-in walker. Not yet pulling to stand frequently or walking independently. ASSESSMENT 1. Well-child visit, 12 months (ICD-10: Z00.129). Growth parameters at approximately 50th percentile, appropriate for age. Meeting language and social milestones. 2. Gross motor delay, mild (ICD-10: R62.0). Not yet walking independently or frequently pulling to stand at 12 months. However, walks supported in walker and crawls well. Hip laxity noted on exam which may be contributing factor. This is within normal limits for age as independent walking is not expected until 12-18 months, with evaluation typically triggered if not walking by 18 months. Family history of later walking in siblings (13-16 months). Will monitor with anticipatory guidance. PLAN Reassurance provided that not walking at 12 months is developmentally normal and does not warrant concern until 18 months if no progress. Discussed strategies to encourage walking: increase floor time for practice, use push walker (shopping cart style) for stability and support, place desired objects out of reach to motivate pulling to stand, allow practice with supportive shoes versus barefoot to see preference. Mother counseled that motivation often drives skill acquisition at this age - wanting to carry objects or keep up with siblings often prompts walking. Hip laxity noted which may contribute to slower progression; will continue to monitor. Encouraged limiting time in sit-in walker. DTaP vaccine administered today (single antigen formulation used per family preference for separated vaccines). Return precautions: monitor injection site for redness, swelling; acetaminophen or ibuprofen as needed for fussiness. If no progress in motor skills over next several months or regression noted, return for evaluation. ANTICIPATORY GUIDANCE Discussed strategies to encourage walking including floor time, push walkers for stability, and creating motivation through desired objects. Reassured that skill acquisition often happens suddenly once child is ready. Discussed that some children prefer shoes for stability while others prefer barefoot - encouraged experimentation. FOLLOW-UP Return for next well-child visit or sooner if concerns about motor development, regression in skills, or no progress noted over several months. ICD-10 CODES Z00.129 - Encounter for routine child health examination without abnormal findings R62.0 - Delayed milestone in childhood CPT CODES 99391 - Periodic preventive medicine, established patient, infant (age younger than 1 year) ───────────────────────────────────────── CODES: CPT 99391 | ICD-10 Z00.129, R62.0