Well Child Visit (15 mo – 2 yr)

Subjective:
Chief Complaint:
Follow-up for nasal issues and low appetite

BF4 - Accompanied By:
Lucas is accompanied by his father.

BF4 - Concerns and Questions:
The caregiver expresses concern regarding Lucas's persistent selective eating habits, specifically his avoidance of rice, meats, and most vegetables, and inquires about his low appetite.

BF4 - Recent Illness:
No recent illnesses or urgent care visits are reported.

Interval History:
Since the previous visit in November, Lucas's nasal symptoms have improved with the prescribed nasal spray, now limited to nocturnal nasal congestion. His appetite remains selective, with a preference for fruit and sweets and avoidance of rice, meats, and most vegetables. The family has implemented more balanced and varied meal options. Lucas's weight has increased from 27.7 kilograms in early January to 29.1 kilograms on February 8th, indicating a gain of approximately 1.5 kilograms in one month.

BF4 - Nutrition:
- Appetite: Selective
- Variety: Limited, with preference for fruit and sweets; avoids rice, meats, and most vegetables
- Iron: No specific sources reported
- Fruits/Vegetables: Consumes fruit; avoids most vegetables
- Calcium: No specific sources reported
- Water: Not specified
- Juice: Not specified

BF4 - Dental Home:
- Dental Home: Not specified
- Last or next dental visit: Not specified
- Brushing: Not specified
- Fluoride: Not specified

BF4 - Elimination:
- Toilet-trained: Not specified

BF4 - Sleep:
- Bedtime: Not specified
- Wake Time: Not specified
- Naps: Not specified

BF4 - Behavior:
No behavioral concerns are reported.

BF4 - Physical Activity:
- Playtime: Not specified
- Screen Time: Not specified

Objective:
Vitals:
- Weight: 29.1 kilograms (15th percentile)
- Height: Above average (exact value not specified)
- BMI: Not specified

Assessment and Plan:
- Allergic rhinitis (J30.9): Lucas's nasal symptoms have improved with the use of the prescribed nasal spray, with residual nocturnal nasal congestion.
Plan:
• Continue current intranasal corticosteroid therapy as previously prescribed.
• No urgent follow-up required at this time.
• Reassessment of symptoms recommended during the next scheduled visit in July or August.
• Provided counseling to the parent regarding ongoing management and monitoring of nasal symptoms.


- Pediatric feeding difficulties (R63.3): Lucas continues to exhibit selective eating behaviors, preferring fruits and sweets while avoiding rice, meats, and most vegetables. Despite this, he has demonstrated a weight gain of approximately 1.5 kilograms over one month, with weight tracking at the fifteenth percentile and height above average, consistent with previous growth patterns.
Plan:
• Advised continuation of offering a variety of nutritious and balanced food options without coercion.
• Recommended limiting intake of sugary foods.
• Encouraged ongoing parental efforts to diversify diet and maintain balanced meals.
• Scheduled follow-up for growth and nutritional reassessment in July or August, with the clinic coordinator to arrange the appointment.
• Provided education to the parent regarding healthy eating habits and the importance of balanced nutrition for growth and development.

Anticipatory Guidance:
Guidance is provided to continue offering nutritious and varied food options without coercion, and to limit sugar intake, particularly given Lucas's tendency to seek out sweets. The importance of balanced meals and ongoing monitoring of growth is emphasized. The family is advised to schedule a follow-up visit in the summer to reassess growth and nutritional status.