SUBJECTIVE:
2-week old infant born to a _ year old G_ at _. No parental concerns/questions today.
ROS:
- Eating well: _
- No concerns about stooling or voiding.
PM/SH:
Normal pregnancy and delivery.
DEVELOPMENT:
- Gross motor: Lifts head when on tummy.
- Fine motor: Moving all limbs equally.
- Cognitive: Starting to smile. Eyes are tracking objects/bright lights.
- Social/Emotional: + consolable. Appears to regard faces of others (at about 12 inches).
- Communication: Coos.
SOCIAL HX:
No smokers in the home. Stable, tranquil family. No major social stressors at home. Mother is doing well.
FAMILY HX:
No h/o SIDS, atopic disease
OBJECTIVE:
- VITALS: _
- WEIGHTS: BW _. Today's weight _.
- GEN: Normal general appearance. NAD.
- HEAD: NCAT. No cephalohematoma. AFOSF.
- EENT: Red reflex present bilaterally. Normal ext ears, nose, lips.
- MOUTH: MMM. Normal gums, mucosa, palate, OP.
- NECK: Supple.
- CV: RRR, no m/r/g. Normal femoral pulses.
- LUNGS: CTAB, no w/r/c.
- ABD: Soft, NT/ND, NBS, no masses or organomegaly. Normal umbilicus.
- GU: Normal _male genitalia. Testes descended bilaterally.
- SKIN: WWP. No jaundice, new skin rashes, or abnormal lesions. No sacral dimple.
- MSK: Normal extremities & spine. No hip clicks or clunks. No clavicular fracture.
- NEURO: MAE symmetrically. Normal moro & suck reflexes. Normal muscle tone.
NEWBORN SCREEN:
- Results all negative.
ASSESSMENT/PLAN:
* Healthy 2-week old infant, doing well.
- F/u at 6-8 weeks of age, or sooner PRN.
* Anticipatory guidance (discussed or covered in a handout given to the family)
- Normal newborn feeding and sleep patterns
- Infant should always sleep on back to prevent SIDS
- Tummy time
- Range of normal bowel habits
- No smoking in home: risk for SIDS and asthma
- Safest to sleep in crib or bassinet
- Car seat facing backward until 2 years of age and 20 pounds
- Working smoke alarms and carbon dioxide monitors in home
- No smokers in the home
- Hot water heater to less than 120 degrees
- Fall prevention
- Normal crying versus colic, and what to expect
- Warning signs for postpartum depression versus baby blues
- Sibling envy
- No honey, corn syrup, cows milk until 1 year
- Formula mixing
- Poly-Vi-Sol supplement with iron if mostly breast feeding (< 32 oz/day of formula)
- How and when to contact us