Office Visit Note
Narrative: CHIEF COMPLAINT 12-month well child visit HISTORY OF PRESENT ILLNESS Daisy is a 12-month-old female presenting for her well child visit. Her mother reports she is doing well overall, described as "crushing it" and "sweet as can be." She took her first steps yesterday. She currently has 2 teeth, which erupted around 9 months; the top 2 teeth may be starting to come in. Mother notes she seems petite compared to her older brother but has no concerns. She is currently on 2 naps per day, which is working well. Bedtime is typically between 8:00 and 8:30 PM, though summer evening activities have been disrupting the schedule. She falls asleep easily in the car, which can push bedtime to as late as 10:00 PM on occasion. Parents report she is an overall happy child. She is still breastfeeding approximately 3 times daily — before each nap and at bedtime. She also wakes overnight to nurse. Mother is interested in weaning, particularly night weaning, before the family relocates to Utah after Labor Day. Mother is currently pregnant. She nursed her older child until approximately 15 months. Mother asks about introducing cow's milk or goat milk now that Daisy is 1 year old. The family plans to return to Utah in early September and will likely miss the 15- and 18-month well child visits in person; virtual visits were discussed as an option. REVIEW OF SYSTEMS No acute concerns reported. No fevers, rashes, respiratory symptoms, vomiting, diarrhea, or behavioral concerns noted. Sleep is generally adequate with occasional late bedtimes due to schedule disruptions. Feeding and appetite are good. Development progressing well per parent report. PHYSICAL EXAM General: Well-appearing, happy, interactive 12-month-old female. Weight: Approximately 50th percentile (up from approximately 36th percentile at prior visit). Development: Age-appropriate. First steps taken. Dentition: 2 lower teeth erupted; upper teeth beginning to emerge. Provider states development is "100% perfect." ASSESSMENT 1. 12-month well child visit — growth, development, and milestones age-appropriate. Weight has improved from approximately 36th to 50th percentile. 2. Dentition — only 2 teeth erupted at 12 months; discussed genetic variation in teething patterns. Not concerning given first teeth erupted at 9 months. 3. Sleep schedule disruption — intermittent late bedtimes related to summer evening activities and car naps; otherwise adequate sleep routine. 4. Breastfeeding and weaning counseling — mother interested in night weaning and transitioning feeding as child approaches toddlerhood; mother is currently pregnant. 5. Immunization — MMR vaccine due; administered today given current measles prevalence. Family prefers one vaccine at a time. PLAN 1. Well child visit: Growth is reassuring with weight trending from 36th to 50th percentile. Development is age-appropriate with first steps taken yesterday. Continue monitoring at upcoming visits. The 15- and 18-month visits will likely be conducted virtually given family's planned relocation to Utah. An additional in-person visit will be scheduled for late August to administer further vaccines before departure. 2. Dentition: Reassured mother that teething pattern is genetically determined and varies between children. First teeth erupted at 9 months, which is appropriate. No intervention needed. 3. Sleep: Validated the family's approach to fitting Daisy's schedule into the family routine rather than reorganizing the household around one child. If initiating sleep becomes more difficult, magnesium (children's gummies or magnesium bicarbonate powder, which the family already uses) can be considered as a sleep aid. Melatonin was discussed and not recommended. 4. Weaning and nutrition: Mother counseled that cow's milk or goat milk is not required if breastfeeding continues. Once weaned, any milk is acceptable but should not be given in excess, as excessive milk intake can displace solid food nutrients. Encouraged advancing table foods with attention to choking hazards, particularly foods accessible from older sibling's plate. For night weaning, discussed that cold turkey approach is likely easiest, though it depends on the child. Recommended night weaning before Utah move, particularly given mother's current pregnancy and the importance of maternal sleep. Daisy does not require overnight feeds at this age. 5. Immunization: MMR vaccine administered today. Counseled on expected side effects including fever (102–103°F) in 15–20% and measles-like rash in approximately 15%, occurring 7–10 days after vaccination, lasting 24–36 hours. Family prefers single-vaccine approach to identify any potential reactant. Plan for additional vaccine(s) at late August visit. ANTICIPATORY GUIDANCE Safety counseling provided: discussed choking hazards with table food introduction, particularly with older sibling's food (Legos, small pieces). Water safety discussed — family reports life jacket rule at cabin. Car seat safety implicitly addressed. Discussed general approach to family scheduling and fitting the toddler's needs into the household routine. Discussed flu vaccine — more beneficial under age 3 due to higher disease risk; can use nasal formulation when older. COVID vaccine discussed briefly — complex recommendations reviewed; hybrid immunity from natural infection plus vaccination noted. FOLLOW-UP Return in late August for additional vaccine administration before family's move to Utah. 15- and 18-month well child visits to be conducted virtually. ICD-10 CODES Z00.129 - Encounter for routine child health examination without abnormal findings CPT CODES 99391 - Preventive medicine, established patient, infant (age under 1 through 11 months) — note: patient is 12 months, clinician should verify correct age-band code ───────────────────────────────────────── CODES: CPT 99391 | ICD-10 Z00.129