Pediatric Preventive Care Visit Note

Chief Complaint

• 12-month well-child check
• Dry skin on arms and legs

HPI

1. Leo Vance is a 12-month-old male (DOB: 14/04/2025, MRN: 849-204-11) presenting with his mother for a routine 12-month preventive care visit. Mother reports no recent acute illnesses, fevers, or developmental concerns. Sleep is well-consolidated at 11 hours nightly with two daytime naps.
2. Mother notes patches of dry, erythematous, pruritic skin on the bilateral antecubital fossae and extensor surfaces of the lower legs over the past 3 weeks. Symptoms worsen after bathing. No oozing or crusting noted.

Social History

Lives in a single-family home with mother, father, and a 4-year-old sister. Attends daycare 3 days per week. No tobacco smoke exposure inside the home. Pet dog at home. No recent household stressors or relocations.

Growth and Vital Signs

Weight: 10.2 kg (65th percentile) Length/Height: 76.0 cm (58th percentile) Head Circumference (FOC): 46.5 cm (60th percentile) BMI (if applicable): Not applicable Blood Pressure (if applicable): Not applicable Pulse Oximetry (if applicable): 99 % on room air

Developmental Assessment

12 Months: Cruises along furniture and walks holding one hand. Uses "mama," "dada," and "ba" (ball) specifically. Waves bye-bye, plays pat-a-cake, and points to desired objects. Demonstrates good joint attention.

Dietary History

Transitioning from iron-fortified formula to whole cow's milk (currently taking 480 mL/day via sippy cup). Eats 3 meals and 2 snacks of soft table foods daily, including meats, fruits, and vegetables. Stopped bottle use last week. Taking colecalciferol (Vitamin D3) 400 IU PO daily.

Review of Systems Constitutional: Denies fever, lethargy, or weight loss. Eyes: Denies discharge, redness, or strabismus. Ears, Nose, Throat: Denies ear pulling, rhinorrhea, or cough. Cardiovascular: Denies cyanosis or diaphoresis with feeds. Respiratory: Denies wheezing, tachypnea, or shortness of breath. Gastrointestinal: Denies vomiting, diarrhea, or constipation. Passing 1-2 soft stools daily. Genitourinary: Normal wet diapers (6-7 per day), no foul-smelling urine. Musculoskeletal: Denies joint swelling or decreased movement of extremities. Skin: Reports dry, itchy red patches on arms and legs. Denies easy bruising or petechiae. Neurologic: Denies seizures, tremors, or regression of milestones. Psychiatric: Pleasant mood, appropriate stranger anxiety. Endocrine: Denies polydipsia or polyuria. Hematologic/Lymphatic: Denies swollen lymph nodes or prolonged bleeding. Allergic/Immunologic: Denies known food or environmental allergies.

Physical Exam Constitutional: Well-appearing, well-nourished male infant, alert and interactive in mother's lap. Vital Signs: T 36.8 °C, HR 118 bpm, RR 26 breaths/min, SpO2 99 % (recorded at 09:15 America/Chicago). Head: Normocephalic, atraumatic. Anterior fontanelle nearly closed, flat. Eyes: PERRL, EOMI. Bilateral red reflex symmetric and intact. No conjunctival injection. Ears, Nose, Throat: TMs pearly grey with normal landmarks bilaterally. Nares patent, turbinates normal. Oropharynx clear, moist mucous membranes, 6 erupted teeth without caries. Neck: Supple, full range of motion, no lymphadenopathy. Cardiovascular: RRR, normal S1/S2, no murmurs, rubs, or gallops. Femoral pulses 2+ symmetric. Capillary refill < 2 seconds. Respiratory: Lungs clear to auscultation bilaterally, no wheezes, rales, or rhonchi. Normal work of breathing. Gastrointestinal: Soft, non-tender, non-distended. Normoactive bowel sounds. No hepatosplenomegaly. Genitourinary: Normal circumcised male. Testes descended bilaterally. No inguinal hernia. Musculoskeletal:

• Bilateral hips: Full ROM, negative Barlow and Ortolani maneuvers, symmetric gluteal folds.
• Upper and lower extremities: Normal tone and 5/5 strength symmetric throughout, no joint effusion or deformity. Skin: Mildly erythematous, xerotic plaques noted in bilateral antecubital fossae and anterior tibiae without excoriation, weeping, or honey-colored crusting. Neurologic: Cranial nerves II-XII grossly intact. Age-appropriate tone and reflexes. Psychiatric: Alert, engages with examiner, exhibits appropriate social smile and eye contact.

Screenings

Point-of-care Hemoglobin: 11.8 g/dL (Normal). Capillary Blood Lead Level: < 1.0 mcg/dL (Normal).

Vaccinations

MMR #1, Varicella #1, Hepatitis A #1, PCV15 #4 administered today.

Anticipatory Guidance

Discussed keeping child in a rear-facing car seat until reaching maximum height or weight limits. Reviewed home childproofing, securing furniture, locking cabinets, and keeping the Poison Control number (1-800-222-1222) accessible. Advised brushing teeth twice daily with a rice-sized smear of fluoridated toothpaste and scheduling a first dental visit. Recommended limiting whole milk to 480-720 mL daily to prevent iron-deficiency anemia, and avoiding all screen time.

Specialist Care

1. Dr. Sarah Jenkins, Pediatric Dermatology

Assessment & Plan

Well Child Check Assessment: Healthy 12-month-old male meeting all age-appropriate gross motor, fine motor, language, and social developmental milestones. Growth parameters tracking appropriately along the 58th-65th percentiles. Point-of-care hemoglobin and lead screenings completed today are within normal limits. Routine 12-month immunizations administered without immediate adverse reaction.

Plan

• Administer MMR, Varicella, Hep A, and PCV15 vaccines today.
• Paracetamol (acetaminophen, Tylenol®) 160 mg/5 mL suspension: give 3.5 mL (112 mg) PO q6h PRN post-vaccination fever or discomfort.
• Continue colecalciferol (Vitamin D3) 400 IU PO daily.
• Limit whole cow's milk intake to max 720 mL/day and offer iron-rich solid foods.
• Referral placed to Pediatric Dentistry for routine establish-care visit within the next 6 months.

1. Atopic dermatitis, mild (ICD-10: L20.9) Assessment: Mild flaring of atopic dermatitis on flexural creases of upper extremities and extensor surfaces of lower extremities, likely exacerbated by seasonal changes and bathing habits. Contact dermatitis is less likely given the classic distribution and lack of new exposures. No signs of secondary bacterial superinfection (impetigo) at this time.

Plan

• Hydrocortisone 1% ointment: apply a thin layer topically to affected red areas BID for up to 7-10 days during flares.
• Apply thick, fragrance-free emollient (e.g., petrolatum or ceramide cream) topically TID, especially within 3 minutes of exiting a lukewarm bath.
• Avoid harsh soaps and bubble baths; use mild cleanser only.
• Follow up with Dr. Sarah Jenkins (Pediatric Dermatology) in 6 weeks if refractory to topical regimen.

Follow-up

Return in 3 months for the 15-month well-child check (after 14/07/2026).

Call the clinic or seek urgent care if the skin rash develops pus, spreading redness, or warmth, or if the patient develops a persistent fever following vaccinations.