Well Child Check: 6-8 week

6-8 WEEKS

SUBJECTIVE:

_-week old infant here for a routine well child check and vaccines. No parental concerns/ questions today.

ROS:

- Eating well: _

- Stooling/voiding normally.

- Behaving normally.

- No concerns about sleep at this time.

PM/SH:

Normal pregnancy and delivery. No surgeries, hospitalizations, or serious illnesses to date.

DEVELOPMENT:

- Gross motor: Able to hold head somewhat steady when pulled to a sitting position. Able to push body up when prone.

- Fine motor: Moving all extremities symmetrically. Can hold an object briefly.

- Cognitive: Indicates boredom when minimal stimulation. Eyes track well, and can fix on objects.

- Social/Emotional: Smiles, looks at parents, able to comfort self.

- Communication: Coos, vocalizes. Has different cries for different needs.

SOCIAL HX:

No smokers in the home. Stable, tranquil family. No major social stressors at home. Mother is doing well. Daytime care is _

FAMILY HX:

No h/o SIDS, atopic disease

OBJECTIVE:

- VITALS: _

- WEIGHTS: BW _. Today's weight _.

- GEN: Normal general appearance. NAD.

- HEAD: NCAT. AFOSF.

- EYES: Red reflex present bilaterally. Light reflex symmetric. EOMI, with no strabismus.

- ENMT: TMs, nares, and OP normal. MMM. No abnormal oral lesions.

- NECK: Supple, with no masses.

- CV: RRR, no m/r/g. Normal femoral pulses.

- LUNGS: CTAB, no w/r/c.

- ABD: Soft, NT/ND, NBS, no masses or organomegaly.

- GU: Normal _male genitalia. Testes descended bilaterally.

- SKIN: WWP. No jaundice, new skin rashes, or abnormal lesions.

- MSK: Normal extremities & spine. No hip clicks or clunks.

- NEURO: MAE symmetrically. Normal muscle strength and tone.

NEWBORN SCREEN:

- Results all negative.

ASSESSMENT/PLAN:

* Healthy newborn infant, doing well.

- Routine care.

- F/u at 4 months of age, or sooner PRN.

* Vaccines today:

- Pediarix #1 (DTaP, IPV, HepB #2), PCV #1, Rota #1, Hib #1

- Pentacel #1 (DTaP, IPV, Hib), PCV #1, Rota #1, HepB #2

- Comvax (Hib #1, HepB #2), PCV #1, Rota #1, DTaP #1, IPV #1

* Anticipatory guidance (discussed or covered in a handout given to the family)

- Common immunization SE’s

- Nutrition and feeding; growth spurts

- Normal 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 (ideally 2) 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 adjustment

- 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