Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1068C (07/08)

STATE OF WISCONSIN Reprinted and adapted with permission from Memee K. Chun, M.D.

GENERAL PEDIATRIC CLINIC / 4 MONTH VISIT
(See 2nd page for Anticipatory Guidance for 4 months) Completion of this form is voluntary.

Patient Name Accompanied by
Parental Concerns

Date of Birth

Age

Height

Weight

Today's Date

Head Circumference
Alertness Activity Response to Examiner

Feeding: Breast ________________ x/day, ____________ hours Formula: Type _____________ ( ) ________________ x/day Amount / Feeding ____________ oz. Water ___________ x/day Solids Sleeping

Note ­ Present (+) or Absent (-) as Appropriate (Cross off parts not examined or not applicable) Part Skin: Color, texture Head: AP size _____ / cms _____ Eyes: Cover test, lids, pupils, conjunctivae, red reflex fundi Ears: Canals, tympanic membranes, localization of sound Nose & Mouth & Throat: Gums, buccal mucosa, tongue Neck & Chest: Trachea, thyroid, cervical nodes Heart and Lungs Abdomen: Size, liver, spleen, kidneys Extremities: Hips ­ abduction _______ click ( ) Tibial malleolar positions _______ feet ____________ Genitourinary: Penis, meatus, foreskin retraction, testes, vaginal orifice, inguinal nodes, inguinal hernia ( ) Neuromuscular: Tone, posture, head control, motor strength, C2-12, reflexes, moro ( ) placing ( ) palmar grasp ( ) plantar grasp ( ) tonic neck ( ) babinski ( ) DTRs Describe abnormal findings. N Abn

Skin

Stool Pattern

Reaction to Previous Immunization

Current Living Situation

Parents' Description of Baby's Temperament

Problems Identified and Received

Developmental Observations NO*. = Not Observed by parents or R. O. NO* examiners R. = Reported, O. = Observed
G.M. Rolls over from stomach to back Prone, lifts, chest up with arm support No head lag when pulled to sitting Head steady when held sitting Bears some weight on legs Regards & follows small object ­ 90° arc Reaches for dangling object Brings hands together Grasps objects and resists pull Laughs aloud Vocalizes responsively Initiates vocalization Seeks eye contact with parent Reaches with arms to parent Smiles responsively

Physical and Emotional Status P.M.

Diet: Change in Stool with Diet, Scheduling to Fit Family Schedule Additions

Lang.

Anticipatory Guidance: Drooling, Chewing, Teething, Pacifier. Colds and Fever Review Sibling Rivalry. Vocal Stimulation Safety: Need for Safe Place to Leave Baby, Toys, Aspiration of Foreign Objects. Home Water Temp. Immunization DTaP Hib IPV PCV Drug Co. & Lot No. Expiration Date

P.S.

Parent's Interactions with Baby NO* = Not observed here O. NO* O. = Observed M = Mother F = Father
Touches baby Scolds crying baby Calmly holds to quiet baby Spontaneously identifies baby's positive qualities Watches baby's action during visit Responds to baby's voice with vocal response Other observations

____________________________
SIGNATURE ­ Provider
Return to clinic in _____ months.

______________
Date Signed

Development and Parent-Child Interaction

General Pediatric Clinic / 4 Month Visit F-1068C (07/08)

Anticipatory Guidance for 4 month visit Page 2

Diet Plan adding only one new food per week. It is okay to let the parents choose what to add but still keep away from allergenic foods. With addition of solids, stools will become more firm. Add juices and fruits p.r.n. (see 6-8 week visit). Anticipatory Guidance Teething, discuss the timing of first teeth (5-9 months), the wide range of normality, the normal sequence of teeth eruption and again great variation in this sequence, gums do most of the chewing so the baby does not need teeth to eat solids. Drooling, increased mucus, irritability, need to chew, possibly loose stools may all be related to teething. Most babies do not have fever, runny nose or overt diarrhea. Drooling is also due to increased saliva at this age. Chewing is partially from teething but also from the development of "hand-mouth" reflex. A cool pacifier gives comfort to the swollen gums. Use solid teething ring kept cool in the refrigerator. Do not use a ring with liquid inside. Colds ­ see handout. Discuss decreased maternal protection by 6 months. More exposure to people and so babies are more apt to get viruses. Diseases may last 7-14 days and the baby can get a new "cold" every two weeks or so. Fever review ­ see "6-8 week visit"

Sibling Rivalry The baby is now very responsive to everyone and gets a lot more attention from father and visitors. Sibs close in age may show more signs of sibling rivalry now. May revert to more immature behaviors. Vocal Stimulation ­ The parents should respond to baby's "noises" with speech. Safety Use the playpen as a safe place to leave the baby. This is especially needed when there are older sibs running around. The use of the playpen at this time will get the child used to his own "safe territory". As the baby becomes more mobile, the playpen can prevent accidents from occurring when the baby is left alone for a few minutes while the parent goes to the bathroom, answers the phone, goes to the front door, etc. When using infant seats, they should always be placed on the floor. Toys should be large, colorful and washable. The prevention of aspiration of objects should be gone over by reminding parents to always close safety pins and not leave small toys or hard food near the baby. Home water temperature should be turned to below 120° now.