Well child – 4 mo

Sep 19, 2018 • Mark Morgan

categories: Pediatrics

HISTORY:

provided by parent provided by other unobtainable d/t parental anxiety and/or lack of knowledge interpretation provided by family member interpretation provided by MA
SPECIAL NEEDS:

none specialty
SOCIAL HISTORY:

no changes child care housing single parent working parent siblings maternal depression

REVIEW OF SYSTEMS
Interval change:

doing well, no changes since last visit no illnesses or injuries no specific concerns raised no visits to health care providers, facilities questionnaire provided & reviewed

Nutrition:

no concerns breast formula
Urination:

no concerns
Stooling:

no concerns
Sleep:

no concerns

GROWTH:

chart provided, reviewed, developing well
MILESTONES:

pushes chest up to elbows, adequate head control, rolls over from stomach to back reaches for objects, opens hands, grasps rattle smiles, babbles & coos, responds to affection, social smile, recognizes parent’s voice & touch

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Appearance:

well-appearing active, interactive no distress uncooperative with exam
Skin:

pink, normal turgor no rashes no bruises
Head:

no skull deformities normal anterior fontanelle plagiocephaly
Eyes:

blinks to light, red reflex bil, appears to see no strabismus
Ears:

appears to hear normal canals & TMs
Nose:

nares patent
Mouth:

oral mucosa moist & without lesions teeth absent bottom central incisor(s) present
Throat:

patent pharynx w/o swelling or exudates
Neck:

supple, symmetrical ROM, turns head side to side
Chest:

unlabored respirations, symmetric chest expansion, clear and equal breath sounds bilaterally
Heart:

regular rate & rhythm, no murmurs femoral pulses present & equal
Abdomen:

soft, nondistended, nontender, no obvious palpable masses, bowel sounds normal
Genitalia:

normal appearance uncircumcised circumcised testes down bilaterally
Extremities:

symmetrical FROM, hips w/ good abduction w/o clicks
Back:

normal spine no sacral dimpling
Neuro:

normal reflexes, normal & symmetrical tone/strength

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LABORATORY/OFFICE DIAGNOSTICS:

none normal non-specific changes official report to follow pending

IMMUNIZATION:

per schedule deferred declined

OUTSIDE ORDERS/REFERRALS:

none laboratory studies diagnostic studies specialty WIC

DISCUSSED AND/OR HANDOUT GIVEN/OFFERED:

exam findings & recommendations diagnostic studies development, growth, safety, falls, drowning, no walkers nutrition, trying solids & different foods to avoid allergy, no bottle in bed, oral health daily routines, tummy time, sleep given opportunity to ask questions and state concerns verbalized understanding of instructions & POC

FOLLOW UP:

6 months of age, sooner if concerns arise

Well child – 4 mo

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