Office Visit Note
Narrative: CHIEF COMPLAINT 18-month well child visit with concerns about delayed independent walking, low muscle tone, and ankle instability HISTORY OF PRESENT ILLNESS Tommy is an 18-month-old male presenting for his well child visit. His mother reports concerns about delayed independent walking. He walks well with support (pushing a walker, cruising along furniture), climbs stairs, and essentially runs when pushing his pusher toy. He has taken a couple of independent steps but preferentially drops to crawling, which he is proficient at. He does not yet pull to stand independently in the middle of a room. Mother notes his ankles visibly roll inward (overpronate), which is more apparent when barefoot. She reports he does better in shoes, which provide additional ankle support. She has been practicing with him at home using treats as motivation. Mother reports definite improvement since his 15-month visit, including faster supported walking, more willingness to walk between furniture, and more independent standing. Family history is notable for an older sibling (Luke) who also did not walk independently until approximately 18 months with a similar pattern including prolonged army crawling. Another sibling (Charlie) walked at about 12 months. Mother herself walked at 9 months; paternal walking history is unknown. Speech development is reported as very good with many words, pointing to communicate, and knowledge of animal sounds. He understands what is said to him. Mother is working on tooth brushing. The family is on well water (no fluoride supplementation discussed). Safety concerns include sibling roughhousing, particularly from the middle sibling (Luke), and stair safety — Tommy climbs up well but cannot safely descend stairs. REVIEW OF SYSTEMS Musculoskeletal: Positive for ankle overpronation, delayed independent ambulation. Positive for continued progress in gross motor skills since last visit. Neurological: No regression of skills reported. Speech/Language: Age-appropriate word use and receptive language per parent report. Denies concerns about hearing or social interaction. PHYSICAL EXAM Weight: 24 lbs 3 oz (50th percentile, consistent with prior tracking). Length: 50th percentile (remeasured supine for accuracy). Growth: Both weight and length tracking at 50th percentile, consistent. General: Well-appearing toddler, interactive, engaged with toys and snacks during visit. Musculoskeletal: **Lower than normal muscle tone noted on passive range of motion testing — decreased resistance to passive movement.** **Bilateral ankle overpronation observed with supported ambulation, more pronounced when barefoot.** No fixed positional deformities. No toe walking. Upper extremity strength noted to be good. Neurological: Walks with support, cruises furniture, climbs stairs. Has taken a few independent steps. Drops to crawling as preferred mode of locomotion. Does not independently pull to stand from floor in open space. No abnormal gait pattern aside from pronation. Points, uses words, follows commands — gross receptive and expressive language appropriate. Developmental observation: Good social engagement, eye contact, pointing to communicate, uses multiple words, identifies animal sounds. Fine motor skills observed (coloring with doodle board, manipulating snacks). ASSESSMENT 1. 18-month well child visit — growth tracking at 50th percentile for weight and length, consistent with prior trajectory. Speech and social development age-appropriate. Safety counseling provided regarding sibling interactions and stair safety. 2. Delayed independent ambulation — walking with support and cruising, has taken a few independent steps but not yet walking independently at 18 months. Progressing since 15-month visit, which is reassuring. Family history of similar pattern in older sibling (walked independently at ~18 months). Likely represents normal variant/familial tendency in neuromotor development rather than disorder. 3. Low muscle tone — noted on exam with decreased resistance to passive movement. Not at a level consistent with disorder as functional progress is being made and strength is adequate. Contributing to delayed independent walking and ankle instability. 4. Bilateral ankle overpronation/instability — observed on supported ambulation, worse when barefoot, improved with shoes. Likely related to low tone and ligamentous laxity. May benefit from ankle-foot orthotics (AFOs) if PT assessment supports this. 5. Immunization status review — has received 3 Prevnar and 1 DTaP. No Hib vaccine on record. Due for multiple vaccines including MMR and Hib. PLAN 1. Well child visit: Growth and development reviewed. Growth is reassuring at 50th percentile for both weight and length with consistent tracking. Speech and cognitive development are age-appropriate. Will continue routine monitoring. 2-4. Delayed independent walking, low tone, and ankle instability: Referral to pediatric physical therapy for evaluation and possible strengthening/stabilization exercises. Provided family with local PT options (Sunny Days, Minnetonka Therapy, Capernaum). Family to call and arrange based on availability and insurance coverage. Mother should describe an 18-month-old not yet walking independently who would benefit from a motor evaluation. Shoes providing ankle support should continue to be used. Discussed possibility of ankle-foot orthotics (AFOs) if PT assessment indicates need; braces are more typically indicated for toe walking or significant foot instability. Reassured parents that continued progress is the most important indicator, that this presentation is in the "curious/interesting" range rather than the "worry" range, and that given the family history of a sibling with similar pattern, this likely represents a familial neuromotor variant. Low tone in this context is expected to improve with development and does not currently meet criteria for a disorder. 5. Immunizations: Discussed vaccine schedule. Recommended MMR as priority given rising measles cases nationally (>2,000 cases in the US this year). Also recommended Hib vaccine, which is available as a standalone and would likely be the final dose needed if given now. Parent elected to defer MMR until end of summer. Hib vaccine to be given today. Educated family on MMR series — first dose provides immunity in 80-85% of children, second dose is a catch-up for the 15-20% who did not respond to the first dose rather than a traditional booster. ANTICIPATORY GUIDANCE Safety: Discussed supervision around stairs — recommended allowing Tommy to go up only with supervision and not allowing him to attempt descending stairs independently at this time due to fall risk. Discussed sibling safety and monitoring roughhousing, particularly with preschool-aged sibling who may not modulate his strength appropriately around the toddler. Dental care: Family is working on daily tooth brushing. Discussed fluoride toothpaste use — given family is on well water without fluoride, use of fluoride toothpaste may be appropriate per AAP recommendations; further discussion to follow. Sun and bug safety: Sunscreen use encouraged for all children. For insect repellent, Picaridin or DEET-based products recommended for efficacy. Natural repellents require frequent reapplication and are less reliable. Sticker-type repellents have variable efficacy depending on placement and number used. Thermacell-type area repellent devices discussed as option for outdoor use given large yard. FOLLOW-UP Follow up for well child visit per routine schedule; family to schedule PT evaluation in the interim and may contact the office to arrange visits for siblings before school starts. ICD-10 CODES Z00.121 - Encounter for routine child health examination with abnormal findings R62.0 - Delayed milestone in childhood CPT CODES 99391 - Preventive visit, established patient, infant (age 1-4) ───────────────────────────────────────── CODES: CPT 99391 | ICD-10 Z00.121, R62.0