15 Month Well Child Check

Lucas Miller is here for a 15-month well child check.

Has the following acute problems or concerns today. Mother reports intermittent hard stools and mild straining over the past 3 weeks following the transition to whole cow's milk. No hematochezia, vomiting, or abdominal distension.

Review of Diet and Nutrition

Has a good appetite and eats a varied diet, including table foods with adequate portions of protein-rich foods, iron-rich foods, fruits, and vegetables. Does not drink sugary beverages. Drinks approximately 20 oz of whole cow's milk daily via sippy cup; weaned off bottles. Takes a multivitamin.

Review of Elimination

Normal wet diapers. Stooling every 2–3 days, firm consistency (Bristol Type 2) with mild straining. No anal fissures noted by parents.

Review of Sleep

No sleep concerns. Has a consistent bedtime and sleeps through the night in their own bed (11 hours overnight, plus one 2-hour afternoon nap).

Dental History

Has not yet seen a dentist; first appointment is scheduled for next month. Brushes teeth twice daily with fluoridated toothpaste; does not take a daily fluoride supplement as municipal water is fluoridated.

Development

The parent has no concerns about the child's development or behaviour.

Lucas is meeting the following milestones:

• Imitates scribbling and drinks from a cup
• Points to request something or obtain help
• Looks around when asked questions such as “Where is your ball?” or “Where is your blanket?”
• Uses three words other than names, vocalises in sounds, and follows spoken directions
• Squats to pick up objects, crawls up a few steps, runs, and makes marks with a crayon

Examination

Vitals: Temp 36.8 °C, HR 115 bpm, RR 24 /min, Wt 10.8 kg (60th percentile), Length 79 cm (55th percentile), HC 47 cm (50th percentile). Gen: Alert, active, interactive toddler in NAD. HEENT: Normocephalic, atraumatic. TMs clear bilaterally. Oropharynx clear, 10 erupted primary teeth without visible caries. CV: RRR, normal S1/S2, no murmurs, femoral pulses 2+ bilaterally. Resp: CTAB, no wheezes, rales, or rhonchi. Abd: Soft, non-tender, non-distended, normoactive bowel sounds, no hepatosplenomegaly, small amount of palpable stool in LLQ. GU/Rectal: Normal male genitalia, testes descended bilaterally. Anus patent, normal tone, no fissures or perianal erythema. MSK/Neuro: Moves all extremities symmetrically, normal gait and tone. Skin: Warm, dry, no rashes or lesions.

Assessment and Plan

1. 15-Month Well Child Check

   • Growth and development are appropriate for age.
   • Administered routine immunisations today: DTaP #4, Hib #4, PCV15 #4.
   • Applied topical fluoride varnish in clinic today; advised parents to keep upcoming dental appointment.
   • Provided anticipatory guidance regarding toddler safety (rear-facing car seat, water safety, poison control, stair gates) and limiting screen time.
   • Follow up in 3 months for the 18-month well child check.

2. Mild Functional Constipation

   • Likely secondary to excessive cow's milk intake.
   • Advised limiting whole milk intake to a maximum of 16 oz daily and increasing water intake.
   • Recommended increasing dietary fibre (e.g., prunes, pears, peaches, whole grains).
   • If no improvement with dietary modifications after 1 week, initiate macrogol 3350 (polyethylene glycol 3350, Miralax®) 4 g PO daily mixed in 4 oz of water or juice, titrating to achieve 1 soft stool daily.
   • Return sooner if abdominal pain, vomiting, or bloody stools develop.