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.
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