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:
* 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