Presents for a 15-month well-child check-up
Accompanied by:
Past medical history:
Medications:
Allergies:
Family history:
Known risk factors:
Current symptoms or caregiver concerns:
NUTRITION:
Breastfeeding: , feeds daily
Homogenized milk (500–750 ml or 16-24 oz): daily
Vitamin D 400 IU/day:
Vegeterian diet:
Appetite:
Counseling:
- Avoid foods high in sugar or salt
- Avoid small, hard pieces / choking prevention
- Avoid juice
- Promote independent/self-feeding
- Promote open cup instead of bottle
- Avoid bottles in bed
EDUCATION AND ADVICE:
Sleep (11-14 hrs per day): total hrs per day
Sleep habits: , , ,
Daycare: ,
Living with: ,
Parenting/bonding:
Family conflict/stress:
Second hand smoke exposure:
Complementary/alternative medicine:
Counseling:
- Encourage reading
- Avoid screens
- Promote physical activity
- Poison prevention (poison control center)
- Car seat facing back
- Burn pervention
- Protect electric plugs/cords
- Attend during baths
- Safe sleep (avoid bed sharing, crib safety)
- Limit sun exposure / sunscreens
- Dental cleaning
- Fever advice
DEVELOPMENT:
Says 5 or more words (do not have to be clear):
Walks sideways holding onto furniture:
Shows fear of strange people/places:
Crawls up a few stairs/steps:
Tries to squat to pick up toys from the floor:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Measurements: length: cm - perc, weight: kg - perc, head circ: cm - perc
Head: fontanelles ,
Eyes: -R: , -L: ,
Ears: -R: , -L:
Nose: , , discharge ,
Throat:
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Genital: , testicles , penis
Extremities: , , cap refill
Skin:
Musculoskeletal: joints ,
Neurologic: cranial nerves , strength , sensation , reflexes , cerebellar function , gait
Mental status: , , reactive to
Developmental milestones: motor: , communication: , social/emotional: , cognitive: , adaptive:
ASSESSMENT:
DDx:
PLAN:
- Blood work: if at risk of anemia, if at risk, if HBsAg positive mother
- Caregiver questions answered
- Iron supplementation if not consuming iron-rich foods or at risk
- Vitamin D supplementation if breastfeeding or premature
- Referral to dentist
- Follow-up in