Well-Baby 2 Month
Presents for a 2-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 (600-900 mL (20-30 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:
- Encourage reading
- Avoid screens
- Promote physical activity
- 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 (minimum 30 min/day)
- Water not required if exclusive breastfeeding
- No OTC cough/cold medicine
- Temperature control and overdressing
- Fever advice
DEVELOPMENT:
Follows movement with eyes:
Coos - throaty, gurgling sounds:
Lift head up while lying on tummy:
Can be comforted and calmed by touching/rocking:
Sequences 2 or more sucks before swallowing/breathing:
Smiles responsively:
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 (though early for diagnosis), hearing impairment, vision impairment, speech and language delay (though early for diagnosis), 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:
- 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:
- 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: