1 MONTH VISIT

OVERALL_INSTRUCTIONS

Use bullet point format

Template

AGE [age] MEDHX: [Provide the patient's past medical history and any current problems.] Attended by: [Specify who attended the visit, e.g., parent, caregiver, etc.] CONCERNS: [Document any concerns raised during the visit. If there are no concerns, state "No concerns."] FEEDING: [Indicate if there are any feeding issues. Specify the type of feeding method used, such as breast, formula, or a combination of both. Include the frequency of feeding in hours and mention if vitamin D supplementation is provided.] ROS: [Provide observations on the infant's stooling patterns, voiding habits, sleep quality, and sleeping arrangements. Use bullet point style to describe each aspect, ensuring clarity and detail.] SH: [Include any relevant social history information. If mentioned, provide a summary of the mother's current well-being and any concerns related to postpartum depression. Use bullet point style to maintain consistency with the input content.] DEVELOPMENT: [[Provide a summary of the developmental review findings. Include observations on any issues, responses to stimuli such as noise, ability to be comforted, and feeding behaviors such as sucking on breast or bottle.] Example: Nipissing reviewed, «no issues» fixes & follows, startles to noise, calms when comforted, sucks well on breast/bottle] EXAM: [[Document the findings of the physical examination, including vitals and system-specific observations.] Vitals: Ht: [height] HC: [head_circumference] Wt: [weight] [Document any exam findings captured in addition to the general exam below] General - Looks well, alert, no distress, no dysmorphic features HEENT - Anterior fontanel S&F, red reflex normal B/L, sutures approximated, MMM, palate intact, no plagiocephaly CVS - Normal S1/S2, no murmurs, good femoral pulses RESP - GAEB, no increased WOB, no wheeze, no crackles GI - Abdomen soft, non-tender, non-distended, no HSM, no palpable masses, anus patent GU - Normal genitalia, testes descended bilaterally (if male patient) MSK - Hips stable, spine intact, no sacral dimple or hair tuft CNS - Moving all limbs spontaneously, normal newborn reflexes, normal tone DERM - Skin clear, no rashes ASSESSMENT & PLAN: [[Provide a summary of the infant's health status, including growth and development milestones. Include anticipatory guidance on key topics such as feeding, safe sleep practices, night waking, vaccination schedule, diaper and skin care, signs and symptoms of illness, and car seat safety. Use a narrative paragraph style to maintain consistency with the input content.] Example: Healthy 1 month old infant, «good growth & development» Anticipatory guidance on feeding, safe sleep & night waking, vaccines, diaper & skin care, signs/sx of illness, car seats - rear facing discussed] ISSUES/CONCERNS: [Document any issues or concerns identified during the visit. If there are no issues, state "No issues or screening."] VACCINES: None today, reviewed vaccination schedule with parents, to start at 2 months of age FOLLOW UP @ 2 months