9-Month-Old Routine Check-Up
Presents for a 9-month well-child check-up
Accompanied by:
Age: months, 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 (700-950 mL or 24-32 oz): daily, type:
Iron supplement (if prematurity):
Vegeterian diet:
Appetite:
Counseling:
- Eat fruits, vegetables, cow's milk product
- Explore textures
- Avoid foods high in sugar or salt
- Avoid small, hard pieces / choking prevention
- Avoid juice
- Promote independent/self-feeding
- Encourage transition from bottle to cup
- Avoid bottles in bed
EDUCATION AND ADVICE:
Sleep (11-14 hrs per day): total hrs per day
Sleep habits: , , ,
Living with: ,
Parenting/bonding:
Family conflict/stress:
Second hand smoke exposure:
Complementary/alternative medicine:
Counseling:
- Encourage reading
- Avoid screens
- Promote physical activity
- Poison prevention (poison control center)
- Car seat facing back
- Burn pervention
- Protect electric plugs/cords
- Attend during baths
- Safe sleep (avoid bed sharing, crib safety)
- Limit sun exposure / sunscreens
- Dental cleaning
- Fever advice
DEVELOPMENT:
Looks for an object seen hidden:
Cries or shouts for attention:
Babbles a series of different sounds (e.g. baba, duhduh):
Responds differently to diferent to people:
Makes sounds/gestures to get attention or help:
Stands with support when helped into standing position:
Sits without support:
Uses both hands equally:
Opposes thumb and fingers when grasps objects and finger foods:
Plays social games (e.g. nose touching, peck-a-boo):
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:
Investigations:
- Blood work: if premature ou birth weight < 2500g, if at risk, if HBsAg positive mother
Treatments:
- Caregiver questions answered
- Iron supplementation if not consuming iron-rich foods or at risk
- Vitamin D supplementation if breastfeeding or premature
Further care:
- Referral to resources and support for parents if needed
- Follow-up in
EXAM: ASSESSMENT: PLAN: