WCC- 1 Month

DIET: _
Method of feeding: _
Frequency of feeding: _
Amount/duration of feeds: _
Night time awakenings: _
Pacifier use: _
If formula fed - do not prop the bottle
Daily Vitamin D supplementation recommended - 400 IU po q day

ELIMINATION: _

SLEEP PATTERN: Recommended Hours (10.5-18 hours) _
Back to sleep. Have baby sleep in parents room in own crib . Don't use loose, soft bedding
Tummy time when awake.

BEHAVIOR/TEMPERAMENT: _
Never shake a baby
Fussy times _
Reassure parents can be normal behavior

DEVELOPMENT:
Do you have any concerns about your child's development, behavior, or learning? _
Starting to smile, able to follow parents with eyes. Able to hold up head when prone, moves arms/legs equally, recognizes parents voice.

SOCIAL HISTORY: _
How are the parents feeling: _
Back to work/school plans : _
Take time for self, partner . _


Screenings: 
No qualifying data available.
Results: 
No qualifying data available.


PHYSICAL EXAMINATION: Alert, engaging, pink. No apparent distress. Well developed. Well nourished.

HEENT: Head: Anterior fontanelle soft, flat. Sutures apposed. Normocephalic. Eyes: Bilateral RR. Conjunctivae pink without discharge. Ears: B/L tympanic membranes with normal landmarks; no erythema. Nose: Clear. No discharge. Mouth/throat: No oral lesions. The pharynx is without exudates or erythema.

NECK: Supple. No significant lymphadenopathy. No torticollis.

LUNGS: Clear to auscultation with equal breath sounds. No wheezes, rales or rhonchi.

HEART: Regular rate and rhythm; normal S1/S2. No murmur. Femoral pulse 2+ and equal.

ABDOMEN: Soft, nontender, normal bowel sounds. No hepatosplenomegaly. No masses. No hernia.

GENITOURINARY: _

ANUS: No fissures or swellings. SKIN: No lesions noted.

EXTREMITIES: No hip clicks noted; symmetric creases and normal range of motion. Ortalani/Barlow Maneuver Negative

NEUROLOGIC: Normal tone. Cranial nerves grossly intact. Motor/sensory grossly normal.

SPINE: Normal curvature with no defects or dimples.




ASSESSMENT/PLAN: 1) 1 month well child check - Normal growth/development

ANTICIPATORY GUIDANCE: Discussed. Age appropriate handouts given. Contains information on normal infant behaviors, feeding, safety and routine care .
Safety area discussed: Use rear-facing car safety seat. Do not leave baby unattended on changing tables, furniture, keep toys with loops, string/cords away from baby

Parents concerns reviewed and questions answered .

Follow-up -1 month PRN.