4-Month Well-Child

Presents for a 4-month well-child check-up

Accompanied by: ‍both parentsmotherfather





Past medical history: ‍ ‍none

Medications: ‍ ‍none

Allergies: ‍ ‍none

Family history: ‍ ‍unremarkable

Known risk factors: ‍ ‍none



Current symptoms or caregiver concerns: ‍ ‍none



NUTRITION:

Breastfeeding: ‍yesno, ‍ feeds daily

Vitamin D 400 IU/day (if breastfeeding): ‍yesno

Formula feeding/Preparation (750-1080 ml (25-36 oz)/kg/day): ‍ ‍mloz daily, type: ‍

Regurgitation: ‍yesno

Iron supplement (if prematurity): ‍yesno

Discuss future introduction of solids, with emphasis on iron containing and allergenic foods

Stool pattern and urine output: ‍ ‍normal



EDUCATION AND ADVICE:

Sleep: total ‍ hrs per day

Sleep habits: ‍only on back ‍sleeps in crib/own bed

Living with: ‍both parentsmotherfather, ‍siblings

Parenting/bonding: ‍goodaveragepoor

Family conflict/stress: ‍yesno

Parental fatigue/postpartum depression: ‍yesno

Difficulty making ends meet or food insecurity: ‍yesno

High-risk infants/assess home visit need: ‍yesno

Second hand smoke exposure: ‍yesno

Complementary/alternative medicine: ‍yesno

Counseling:

- Encourage reading

- Avoid screens

- Promote physical activity

- Falls (stairs, change table, unstable furniture/TV, no walkers)

- Carbon monoxide/smoke detectors

- Choking/safe toys

- Protect electric plugs/cords

- Poison prevention (poison control center)

- Car seat facing back

- Burn prevention

- Hot water <49°C/bath safety

- Safe sleep (room sharing, avoid bed sharing, crib safety)

- Limit sun exposure

- Supervised tummy time while awake (minimum 30 min/day)

- Water not required if exclusive breastfeeding

- No OTC cough/cold medicine

- Temperature control and overdressing

- Fever advice

- Dental cleaning



DEVELOPMENT:

Follows a moving toy or person with eyes: ‍ACHIEVEDNOT ACHIEVED

Responds to people with excitement (leg movement/panting/vocalizing): ‍ACHIEVEDNOT ACHIEVED

Holds head steady when supported at the chest or waist in a sitting position: ‍ACHIEVEDNOT ACHIEVED

Holds an object briefly when placed in hand: ‍ACHIEVEDNOT ACHIEVED

Laughs/smiles responsively: ‍ACHIEVEDNOT ACHIEVED

Rests on forearms on belly: ‍ACHIEVEDNOT ACHIEVED

Turns to voice: ‍ACHIEVEDNOT ACHIEVED



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Measurements: length: ‍ cm - ‍ perc, weight: ‍ kg - ‍ perc, head circ: ‍ cm - ‍ perc

Head: fontanelles ‍soft, ‍normocephalic

Eyes: -R: ‍normal, -L: ‍normal, ‍, ‍strabismusnystagmus, red reflex ‍present, corneal light reflex ‍symmetrical, fix and follow test ‍normal

Ears: -R: ‍normal, -L: ‍normal

Nose: ‍clear, ‍nasal flaring, discharge ‍clear, ‍

Throat: ‍normalrednessexudate

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Genital: ‍normal, testicles ‍normal, penis ‍normal

Extremities: ‍normal, ‍normal pulses, cap refill ‍< 3 sec> 3 sec, Barlow ‍negative, Ortolani ‍negative

Skin: ‍no rash

Musculoskeletal: joints ‍ ‍normal, ‍no limited ROM

Neurologic: cranial nerves ‍overall intact, global motricity ‍normal for age, muscle tone ‍normal for age, gait ‍age-appropriate

Mental status: ‍alert, ‍, reactive to ‍

Developmental milestones: motor: ‍, communication: ‍, social/emotional: ‍, cognitive: ‍, adaptive: ‍



ASSESSMENT:

‍Normal growth and development ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Caregiver questions answered

- Iron supplementation if premature

- Vitamin D supplementation if breastfeeding or premature

- Immunizations:

- DTaP-IPV-Hib-Hep B vaccine

- Rotavirus vaccine

- Pneumococcal vaccine

- Meningococcal vaccine if at risk

- Referral to resources and support for parents if needed

- Follow-up in ‍ ‍weeksmonthsat 6 months