Initial Evaluation

Dr. Brown obtains the following information on her initial evaluation:

Patient Profile
  • Diet: Stopped breastfeeding 4 weeks ago. Similac, 6 oz. q5h by bottle; 16 oz. apple juice/day by bottle; oatmeal cereal, pureed fruit, vegetables, meats; small bites of table food and snacks (raisins, cookies)
  • Habits: Has sucked thumb since age 8 weeks of age; uses a pacifier while awake
  • Sleep: Sleeps through night; take 2-hour nap once daily in the early afternoon; uses bottle to fall asleep (nap and bedtime)
Past Medical History
  • Medications: Poly-Vi-Flor 0.25mg with Iron 1 ml/day
  • Allergies: None
  • Immunizations: Up to date although mother reports apprehension about immunizations
  • Injuries/Major illnesses: None
  • Review of Systems: No concerns reported
  • Health care: Sees pediatric nurse practitioner for routine health maintenance; next visit 6 weeks.
Growth and Development
  • Length: 74 cm (75%); Weight: 8.6 kg (50 %)
  • Says "mama" and "dada"
  • Able to stand along
  • Walks with support
  • Follows simple verbal commands
  • Points to desired objects
Dental
  • Tooth eruption: 8 Teeth (upper and lower central/lateral incisors)
  • Hygiene: Mother reports no oral hygiene practices