Office Visit Note
Narrative: CHIEF COMPLAINT Well child visit for approximately 11-month-old with bumpy skin on arms, red cheeks, recurrent staph infections, and diaper area skin irritation HISTORY OF PRESENT ILLNESS Judson is an approximately 11-month-old male (DOB 10/1) presenting for a well child visit. Family recently relocated from Nashville. Mother reports bumpy skin on his arms that she has been trying to treat with thick lotions without improvement. She also notes redness on his cheeks, which she wonders may be related to teething or sensitive skin. Both of her children have had recurrent staph infections; Judson had an abscess on his buttock that required incision and drainage. Mother reports ongoing diaper area skin irritation and is seeking guidance on prevention. The family has previously used EpiClear baths for a few days at a time for staph concerns and currently uses CeraVe for skincare. He is on Bobbie formula. He just started sleeping through the night approximately one week ago. Bedtime routine starts at 7 PM, in bed by 7:30 PM, wakes at 6 AM. Mother reports he is doing well overall. Vaccines are significantly delayed; family prefers a delayed schedule and is not anti-vaccine. He has received two combo vaccines (Pentacel) but no Prevnar. Mother is asking the provider to prioritize vaccines. REVIEW OF SYSTEMS Skin: Bumpy texture on arms, redness on cheeks, history of diaper area irritation. Denies current active abscess or open sores. Sleep: Recently started sleeping through the night. No other acute concerns reported. MEDICATIONS REVIEWED No medications or supplements currently taken. PHYSICAL EXAM Growth: Weight and length greater than 99th percentile. General: Well-appearing, active infant. Skin: **Keratosis pilaris noted on bilateral arms with rough, bumpy texture on triceps areas.** **Red cheeks consistent with sensitive skin complexion.** Diaper area examined. Remainder of exam not specifically documented. ASSESSMENT 1. Well child visit, approximately 11 months old - growth greater than 99th percentile for weight and length. Recently started sleeping through the night. Formula-fed with Bobbie. Vaccines significantly delayed. 2. Keratosis pilaris, arms - characteristic bumpy rough texture on triceps bilaterally. Not amenable to acid-based treatments at this age. 3. Sensitive skin with facial redness - consistent with fair/Irish complexion and heightened skin reactivity to environmental factors. 4. Recurrent staph infections/abscess history - history of buttock abscess requiring I&D. Prone to skin breakdown in diaper area. 5. Diaper area skin irritation - likely contributing to risk of recurrent staph given skin barrier disruption. 6. Delayed immunizations - two combo vaccines received, no Prevnar. Prevnar prioritized as next vaccine. PLAN 1. Well child visit: Growth is robust at greater than 99th percentile. Development appropriate. No supplements needed at this time as nutritional needs are met by formula. Continue Bobbie formula. 2. Keratosis pilaris: Reassurance provided that this is a common, benign skin condition caused by keratin plugging the pores. Acid-based exfoliants are too harsh for his skin at this age. No active treatment recommended at this time. Mother advised to take photos when the appearance changes so we can compare and intervene if it becomes significantly red or inflamed. 3. Sensitive skin/facial redness: Counseled on use of gentle, unscented cleansers such as Cetaphil or CeraVe. Family already uses CeraVe, which is appropriate given ceramide content that helps with moisture retention. Advised to avoid organic/natural ingredient products as these can contain allergens that irritate sensitive skin. Discussed that this complexion will be reactive to cold, heat, dryness, and humidity. 4-5. Recurrent staph/diaper area irritation: Focus is on prevention of skin breakdown to reduce staph infection risk, as staph is a normal skin and nasal colonizer that becomes problematic with breaks in skin integrity. Discussed barrier protection in the diaper area with a combination of Desitin (zinc), Aquaphor, and Lamisil (antifungal) mixed together and applied regularly even in the absence of active rash. Lamisil preferred over Lotrimin as it kills yeast rather than just slowing growth. Discussed option of trying cloth diapers with a diaper service to see if it reduces irritation. Powder also discussed as effective physical barrier. EpiClear baths are fine for acute staph concerns but not recommended for regular daily use. Early treatment of any skin infections is important. Heat application and early intervention recommended if abscess-like lesions recur. 6. Immunizations: Prevnar (pneumococcal vaccine) prioritized as the next vaccine to administer today. Discussed the vaccine schedule in detail with mother who prefers a one-shot-at-a-time approach. RSV vaccine not indicated given his age. Family counseled supportively regarding their delayed vaccine approach. ANTICIPATORY GUIDANCE Discussed age-appropriate sleep expectations; praised current sleep schedule. Discussed skin care approach for fair-complected children including avoidance of scented and organic-ingredient products. Discussed formula nutrition being sufficient without need for supplements at this age. FOLLOW-UP Follow up for next well child visit and continuation of catch-up vaccine schedule. ICD-10 CODES Z00.121 - Encounter for routine child health examination with abnormal findings L11.0 - Acquired keratosis follicularis (keratosis pilaris) CPT CODES 99391 - Preventive medicine, established patient, infant (age under 1 year) ───────────────────────────────────────── CODES: CPT 99391 | ICD-10 Z00.121, L11.0