Well-Baby 1 Month
Presents for a 1-month well-child check-up
Accompanied by:
Age: days, Gestational age: months
Birth length: cm
Birth weight: g
Birth head circumference: cm
Discharge weight: g
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 (450-750 mL (15-25 oz)/kg/day): daily, type:
Regurgitation:
Choking during feeding:
Iron supplement (if prematurity):
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:
- Falls (stairs, change table)
- Carbon monoxide/smoke detectors
- Choking/safe toys
- 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
- Water not required if exclusive breastfeeding
- No OTC cough/cold medicine
- Temperature control and overdressing
- Fever advice
DEVELOPMENT:
Focuses gaze:
Startles to loud noise:
Calm when comforted:
Sucks well on nipple:
Pulls his head off the bed surface on belly:
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: transient tachypnea of the newborn, neonatal jaundice, feeding difficulties, gastroesophageal reflux, infections (e.g., urinary tract infection, sepsis), congenital heart disease, metabolic disorders, neuromuscular disorders, developmental dysplasia of the hip, torticollis, cranial asymmetry (e.g., plagiocephaly), birth trauma, genetic disorders, inborn errors of metabolism, hearing impairment, vision impairment, failure to thrive, nutritional deficiencies, anemia, environmental exposure concerns, attachment issues, behavioral issues
PLAN:
* Varies based on local guidelines
Investigations:
- Hearing screening if not done at birth
- Vision screening if at risk
- Hemoglobinopathy screen (if at risk)
Treatments:
- Caregiver questions answered
- Iron supplementation if premature
- Vitamin D supplementation if breastfeeding or premature
- Immunizations: if HBsAg-positive parent/sibling Hep B vaccine #2
Further care:
- Referral to resources and support for parents if needed
- Follow-up in
EXAM: ASSESSMENT: PLAN: