4-Month-Old Routine Check-Up
Presents for a 4-month well-child check-up
Accompanied by:
Age: days, Gestational age: months
Past medical history:
Medications:
Allergies:
Family history:
Known risk factors:
Current symptoms or caregiver concerns:
NUTRITION:
Breastfeeding: , feeds daily
Vitamin D 400 IU/day (if breastfeeding):
Formula feeding/Preparation (750-1080 mL (25-36 oz)/kg/day): daily, type:
Regurgitation:
Iron supplement (if prematurity):
Discuss future introduction of solids, with emphasis on iron containing and allergenic foods
Stool pattern and urine output:
EDUCATION AND ADVICE:
Sleep: total hrs per day
Sleep habits:
Living with: ,
Parenting/bonding:
Family conflict/stress:
Parental fatigue/postpartum depression:
Difficulty making ends meet or food insecurity:
High-risk infants/assess home visit need:
Second hand smoke exposure:
Complementary/alternative medicine:
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:
Responds to people with excitement (leg movement/panting/vocalizing):
Holds head steady when supported at the chest or waist in a sitting position:
Holds an object briefly when placed in hand:
Laughs/smiles responsively:
Rests on forearms on belly:
Turns to voice:
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Metrics: length: cm - th perc, weight: kg - th perc, head circ: cm - th perc
Head: fontanelles ,
Eyes: conjunctiva/sclera , lids/lashes , , extraocular movements , red reflex , corneal light reflex , fix and follow test
Ears: tympanic membranes , auditory canal on , hearing
Nose: , , discharge ,
Throat: , ,
Neck: , , , , , c-spine
Heart: , ,
Lungs: , ,
Abdomen: , , ,
Genitourinary: external genitalia , testes , penis , Tanner stage
Extremities: , , , , Barlow , Ortolani , , cap refill sec
Skin: on
Musculoskeletal: joints ,
Neurologic: cranial nerves , overall motricity , muscle tone , gait , reflexes
Mental status: , , reactive to
Developmental milestones: motor: , communication: , social/emotional: , cognitive: , adaptive:
ASSESSMENT:
DDx: developmental delay, autism spectrum disorder, hearing impairment, vision impairment, speech and language delay, motor skill delay, cognitive impairment, growth disorders, nutritional deficiencies, anemia, lead poisoning, genetic disorders, metabolic disorders, environmental exposure concerns, attachment issues, behavioral issues
PLAN:
Treatments:
- 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
Further care:
- Referral to resources and support for parents if needed
- Follow-up in
EXAM: ASSESSMENT: PLAN: