Well Child Check

Well Child Check

Healthy 6-month-old male; normal growth and development; routine 6-month immunizations administered.

Potential ICD-10 Codes

• Z00.1 Routine child health examination
• L20.9 Atopic dermatitis, unspecified

Well Child Check – Baby Record

• 6-month routine Rourke Baby Record assessment completed.
  • Thriving on breast milk and newly introduced iron-rich solids.
  • Meeting all age-appropriate developmental milestones.
  • Mild infantile eczema managed with emollients.

Medical History

Patient age: 6 months

Past medical history:

• Uncomplicated term SVD at 39+2 weeks; birth weight 3.4 kg.
• Mild neonatal physiological jaundice (resolved without phototherapy).

Current medical conditions:

• Mild atopic dermatitis (infantile eczema).

Current medications:

• colecalciferol (vitamin D3, D-Drops®) 400 IU PO daily
• paracetamol (acetaminophen, Tylenol®) 120 mg PO q4-6h PRN for post-vaccination fever or discomfort

Allergies: NKDA

Parental Concerns

• Questions regarding safe progression of solid food textures and introduction of allergenic foods.
• Mild dry, erythematous patches on bilateral cheeks and antecubital fossae.

Growth

Weight is 7.9 kg (50th percentile), length is 67.5 cm (50th percentile), and head circumference is 43.5 cm (50th percentile). Growth trajectory continues to track consistently along the 50th percentile across all parameters on WHO growth charts.

Nutrition

Feeding method:

• Breastfeeding and complementary solid foods (iron-fortified infant cereal, pureed vegetables, and pureed meats).

Feeding frequency and amount:

• Breastfeeds 5 to 6 times per 24 hours.
• Solids offered twice daily, taking approximately 2 to 3 tablespoons per meal.

Feeding difficulties:

• None reported; coordinates swallowing well without gagging or choking.

Other:

• Producing 6+ heavy wet diapers daily and 1 to 2 soft, brown stools daily.
• Discussed early introduction of common allergens (e.g., peanut, egg) one at a time.

Education and Advice

• Safe sleep: Continue supine sleeping position on a firm, flat surface; remove loose bedding.
• Injury prevention: Lower crib mattress as infant begins to sit; install safety gates for stairs; keep small objects out of reach; never leave unattended on elevated surfaces.
• Dental health: Wipe gums/emerging teeth twice daily with a soft cloth or brush using a rice-sized smear of fluoridated toothpaste; avoid bottles in bed.
• Parental wellbeing: Mother screening negative for postpartum depression; supported well by partner.

Development

• Gross motor: Rolls from back to front and front to back; sits tripod and briefly unsupported; bears weight on legs when held upright.
• Fine motor: Reaches for and grasps objects; transfers toys from hand to hand; brings objects to mouth.
• Communication: Babbles chains of consonants ("ba-ba", "da-da"); turns head toward sounds and responds to own name.
• Social/Emotional: Smiles, laughs, and engages in back-and-forth vocalizations; shows clear attachment to parents and early stranger awareness.

Physical Examination

General:

• Alert, active, well-hydrated, and interactive infant in NAD. HEENT:
• Anterior fontanelle flat, soft, approximately 1.5 cm x 1.5 cm; normocephalic, no plagiocephaly.
• Red reflex present and symmetric bilaterally; corneal light reflex symmetric; tracks objects well.
• TMs pearly grey and mobile bilaterally; oral mucosa moist; two lower central incisors erupting. Cardiovascular:
• Normal S1/S2, regular rate and rhythm, no murmurs; femoral pulses 2+ and symmetric. Respiratory:
• Good air entry bilaterally, clear to auscultation, no wheezes or crackles, no increased work of breathing. Abdomen:
• Soft, non-tender, non-distended; no hepatosplenomegaly or palpable masses. Musculoskeletal:
• Hips symmetric with full abduction; negative Ortolani and Barlow manoeuvres; normal muscle tone and strength. Genitourinary:
• Normal male external genitalia; bilateral testes descended in scrotum. Skin:
• Mild xerosis and faint erythematous plaques on bilateral cheeks and antecubital fossae without excoriation or secondary infection.

Investigations/Screening

• None currently indicated.

Immunizations

Immunizations received:

• Today (6-month schedule): DTaP-HB-IPV-Hib (Infanrix hexa®) 0.5 mL IM; rotavirus vaccine (Rotarix®) 1.5 mL PO.
• Previously completed: 2-month and 4-month routine BC immunization schedules (DTaP-HB-IPV-Hib, PCV13, Men-C-C, Rotavirus).

Upcoming immunizations:

• 12-month schedule: MMR, Varicella, PCV13, Men-C-C.
• Annual influenza vaccine recommended starting at 6 months of age (during influenza season).

Plan

Follow-up:

• Routine 9-month Well Child Check in 3 months.
• Return sooner PRN for persistent fever > 38.5 °C, lethargy, feeding refusal, or worsening rash.

Referrals:

• None required at this time.

Other:

• Continue daily liberal application of fragrance-free emollient (e.g., petrolatum or CeraVe®) for mild eczema; prescribed hydrocortisone 1% ointment topically BID PRN for up to 7 days for acute flares.
• Continue colecalciferol 400 IU PO daily while breastfeeding.