S: HPI:The newborn patient presents with both parents for her first newborn check up five days post discharge. The patient is a 6 day old female neonate, and the parents are presenting to the clinic because their primary care provider Dr. **** ***** is on vacation out of town. The parents note there were no concerns or complaints, and are only presenting to get their first newborn check up.
Past Medical History: Birth: The child was born by an elected Caesarean Section with a Pfannestiel transverse abdominal incision and a low transverse uterine incision with no complications at 37 weeks gestation (by ultrasound). The delivery was done at Geisinger Hospital in Danville on 6/05/12 at 4:45 PM. The mother had regular prenatal care with her OB/GYN Dr. ***** ******. The mother was HIV(-), HbsAG(-), GBS(-), VDRL(-). Mother was up to date on vaccinations including Rubella and denies any infection of CMV, HSV, or toxoplasmosis. Mother denies gestational diabetes, preeclampsia, or any other gestational complications. Mother denies any use or exposure to EtOH, tobacco, illicit drugs, medications, or illnesses. Upon delivery the child’s APGAR scores were 7 and 9 at one and five minutes respectively. Birth weight was 5lbs. 7oz., birth height was 18 inches, and birth head circumference was 30.0cm. The child was given Hepatitis B vaccine one-hour post delivery. Child was given glucose heel stick at birth with no significant findings. Child was given hearing screening (ABR and OAE) with no significant findings. The parents deny any jaundice or kernicterus. The child took to Gerber Gentle formula immediately with no complications. Discharge weight was 5lbs. 3oz..
Parents educated that it is normal for child to decrease in weight after delivery (up to day 5), but should regain birth weight within two weeks. The parents were educated on expected growth patterns as seen below. Parents educated that weight, height, and head circumference would be monitored throughout childhood development and plotted on a growth curve. Parents told that children usually follow normal growth pattern, but providers are alerted to possible complications with rapid increases or decreases in percentiles over time. Currently the child is at the 5% and on the border of a small for gestational age classification.
Newborn Check Up- 6/11/12
+ 2.0 cm/month
12 Month (1 year)
+ 1.0 cm/month
+ 1.0 cm/month
24 Month (2 year)
+ 1.0 cm/month
+ 1.0 cm/month
Parents educated on importance of keeping child up to date with vaccinations to prevent serious illness and complications. Parents were in favor of all suggested vaccinations and declined any supplemental information on vaccinations. Parents educated on expected immunization schedule proposed below.
Hepatitis B (Given)
DTaP, IPV, HiB, Pneumococcal, Rotavirus
DTaP, IPV, HiB, Pneumococcal, Rotavirus
DTaP, IPV, HiB, Pneumococcal, Rotavirus, Hepatitis B, Influenza (will need another influenza at 7 months, then yearly)
None- Screening: PPD, HgB, Lead
Hepatitis A, Pneumococcal
MMR and Varicella (Live)
DTaP, IPV, HiB, Hepatitis A
MMR, Varicella, DTaP, IPV
Tdap, Meningitis, (then booster at 16 years) HPV (then 2 months after, and 6 months after 1st injection)
Family History: Mother: 26 years old, alive and well
Father: 27 years old, alive and well
Brother: 3 years old, alive and well
Maternal Grandmother: 50 years old, alive and well, diagnosed w/ HTN in past year
Maternal Grandfather: 52 years old, alive and well
Paternal Grandmother: 55 years old, alive and well, Hx. of Migraines
Paternal Grandfather: 56 years old, alive and well, diagnosed with DM type 2 at 50 years old
Social History: Child lives with parents and 3-year-old brother in a house in a quiet neighborhood with little traffic. Parents claim the house has been baby-proofed since before their 3-year-old child was born. Parents deny any pets, pools, decks, or guns in the home. Parents deny any risk of exposure to tobacco smoke, poisons, carbon monoxide, or radon (assessed 2 years ago w/ low levels). Parents claim to be in good emotional and financial state with good family support system. Parents claim brother is excited about baby sister and acting in an appropriate manner.
Allergies: None Known Of
Review of Systems: General: Parents say that the child has been eating about 2oz of Gerber Gentle formula every 3-4 hours. Parents deny any complications while feeding. Parents say the child sleeps about 3.5 hours at a time, wakes, eats then sleeps on back. Parents claim child cries when hungry and ceases when fed. Parents say child opens eyes and startles to noises with limb and grasping movements. Parents deny any fever, chills, or sweats.
Skin: Parents say they are keeping the umbilical cord stump clean with water and drying. Parents deny any redness, swelling, warmth, or discharge from the stump. Parents deny any rash, pallor, itching, lesions, bruising or lesions on skin. Parents deny any changes in hair or nails.
HEENT: Parents claim there was no molding due to C-section delivery. Parents say the anterior fontanel is open with no bulging, retraction or changes. Parents claim the head, eyes and ears are symmetrical with no changes. Parents deny any head trauma, contusions, bruising, lesions, or masses. Parents claim the child will open their eyes and deny any redness or discharge. Parents deny any ear redness, swelling, lesions, or discharge. Parents deny any nasal discharge, atresia, lesions, sneezing, or discharge. Parents deny any natal teeth, tongue-tie, cleft palate, lesions, or redness of the mouth and lips.
Neck:Parents deny any masses, lesions, deviation, stiffness or difficulty swallowing.
Lungs: Parents say the child seems to have symmetrical chest expansion and no pectus carinatum or excavatum. Parents deny any difficulty breathing, tachypnea, apnea, cough, sputum production, wheezing, intercostal retractions, or accessory muscle use while breathing. Parents deny any chest wall lesions, lumps or masses.
Heart:Parents deny any cardiac complications through pregnancy or thus far. Parents deny any visible lifts or heaves, murmurs, swelling, or pallor.
GI: Parents say the child has about 4-5 dirty diapers a day, and usually right after feeding. The stool is soft and tan in color. Parents deny any vomiting, diarrhea, constipation, visible pulsations, masses, lesions, or polyhydraminos during pregnancy. Parents deny any anal redness or irritation.
GU: Parents say the child has about 10 wet diapers a day, and the urine is a clear/yellow color.
Extremities: Parents claim child moves all limbs in writhing manner, and clenches and releases hands and feet. Parents deny any redness, swelling or lesions.
Neurologic: Parents deny any head trauma, seizures, convulsions, tics, or prenatal concerns.
Psychiatric: Parents say the child has been in regular pattern of sleeping and have no behavioral concerns. Parents say they have not seen the child smile yet.
Hematopoietic:Parents say the child is A+ and there is no history of any blood dyscrasias, bruising, or bleeding.
O: Vitals: Height-18in.(5%), Weight-5lbs. 3oz.(5%), Head Circumfrence-30cm(94%), BMI-11.26kg/m2, Temperature-98.2 F (Axillary)
General: The patient is a 6-day-old white female that appears as the stated age. Child was sleeping through initial part of visit and easily awakened with movement and voice stimuli. The child is in no acute distress and does not appear sickly. The child is dressed appropriately, well groomed, and has good hygiene. The parents have the appropriate items in baby bag, are attentive, well educated and nurturing. There are no concerns of neglect, abuse, or poor parenting.
Skin: The skin is soft, well hydrated with intact turgor, warm, and an appropriate soft pink color. The skin has no pallor, cyanosis, rashes, lesions, redness, swelling, or bruising noted. The nails are intact with no pallor, clubbing, redness or lesions. The hair is scant, smooth, and distributed on the head in an appropriate pattern.
Head: The head is normocephalic and the anterior fontanel is 2cm in width with no bulging or depression. The metopic, coronal, sagittal, and lambdoidal sutures are open and symmetrical. There is no evidence of trauma, swelling, redness, deformities, or lesions noted. Symmetrical facies are present.
Eyes: There eyes are symmetrical and at an appropriate width and height on the face. There are no obvious deformities, lesions, redness or discharge on the external exam. The palpebral conjunctiva is moist and pink with the absence of pallor or any lesions bilaterally. The sclera, iris and pupil were all noted on exam as symmetrical in appearance and absent of lesions or deformity. The sclera is moist and not injected bilaterally. The pupils were a size one and round bilaterally with equal direct and consensual light reaction. There is a positive red reflex bilaterally and no evidence of icterus, EOM deficits, or nystagmus.
Ears: External exam reveals no pits or tags in the auricular region. The ears are above the lateral canthus bilaterally and symmetrical in shape and size. External auditory canal is pink in color with no discharge, redness or obstruction noted. Scant light yellow cerumen is noted bilaterally. Tympanic membranes are pearly gray color and intact with all landmarks seen bilaterally including the handle of the malleus and the cone of light in the inferior nasal quadrant. There is no evidence of perforation, infection, fluid levels, or foreign bodies seen.
Nose: External examination reveals a symmetrically distributed nose with no lesions, deformities, redness or trauma. The nasal septum is intact and midline with mobile cartilage and no redness, discharge or deviation noted. The nasal mucosa is pink and moist. The inferior turbinates are patent, pink, and moist. There is no swelling, pallor, discharge or obstruction noted.
Mouth: The vermillion border is symmetrical and without any lesions, swelling, redness or deformity. The oral mucosa is pink and moist with no evidence of any lesions, masses or lumps. There is no evidence of ankyloglossia, natal teeth, Epstein pearls, cleft palate, or bifid uvula. The tongue and uvula are midline with appropriate movement. Wharton’s and Stenson’s ducts visualized without any erythema or obstruction. Tonsils noted bilaterally without any enlargement or exudates. The rooting and sucking reflex are present.
Neck: The neck has appropriate midline position with no evidence of torticollis , webbing, or clavicle fracture. There are no masses, lesions, pulsations, redness or swelling noted. No evidence of accessory muscle use in respiration. The trachea is midline and mobile. The thyroid is palpable with no masses or enlargement noted.
Lymphatics: No lymphadenopathy noted in the occipital, pre/post auricular, submandibular, subtonsilar, submental, anterior/posterior cervical, supra/infra clavicular, axillary, umbilical, femoral, or inguinal nodes.
Chest/Lungs: Chest wall inspection reveals symmetrical, unlabored respiratory effort with no paradoxical movements or deformity. There is a symmetrical 2:1 AP-Lateral ratio. No evidence of intercostal retractions, accessory muscle use, nasal flaring, or labored breathing. Palpation of the chest wall shows symmetrical, full respiratory excursion and no deformity. Percussion is resonant throughout all lung fields. Auscultation reveals clear breath sounds bilaterally with no wheezes, ronchi, or rales heard.
Cardiac: Inspection reveals a visible PMI just lateral to the mid-clavicular line at the fifth intercostal space, and no lifts or heaves. Palpation reveals a PMI the size of a quarter with regular rate and rhythm in inspected region, and no lifts, heaves or thrills. Auscultation reveals regular rate and rhythm, S1 and S2 without any murmurs, rubs, clicks or gallops.
Abdomen: Inspection reveals a protuberant abdomen without any visible rashes, lesions, masses, peristalsis, pulsations, fluid shifts, striae, or hernias. The umbilical cord stump is dry, dark brown, and healing well without any evidence of infection. Auscultation reveals no abdominal, renal, external iliac, or femoral bruits. Bowel sounds are noted in all four quadrants as gurgles and no high pitch tinkling. Percussion reveals tympany in all four quadrants. Palpation reveals a soft, non-guarding abdomen with no masses or pulsations palpated. Deep palpation reveals no hepatomegaly, splenomegaly, abdominal aorta enlargement, and both kidneys trapped.
GU: External inspection reveals appropriate and symmetrical labia majora and minora with no lesions, swelling, redness, or deformity. Urethral meatus is non-erythematous and unobstructed with no discharge. The clitoris is slightly hypertrophied, pink and moist. Vaginal mucosa is pink, moist, and without any lesions, redness, discharge or atresia. Perineum and anus is without lesion, redness or atresia.
Musculoskeletal: Inspection reveals appropriate, symmetrical musculature with no obvious skeletal deformities of the head, trunk, back, upper extremities, lower extremities, hands and feet. There appears to be full active range of motion bilaterally with no tremors, tics or fasciculations. There is no abnormal resistance to passive range of motion including no spasticity or hypotonia. There is no crepitus or increased warmth at the shoulder, elbow, wrist, knee or ankle joints and no clonus at the wrist or ankle. Muscle bulk is measured to be 4 inches in circumference bilaterally with the biceps, and 6 inches in circumference bilaterally at the thigh. The leg length is 7.5 inches bilaterally when measured from the ASIS to the heel. The hand grasp reflex and strength is equal bilaterally at a +5. Movements are uncoordinated but not rhythmic, symmetrical or jerky in nature. There is no evidence of hip dysplasia with the absence of a medial thigh fold, negative galeazzi sign, negative ortolani sign, and negative barlow sign. No evidence on examination of brachial palsy or clubfoot. There is no scoliosis or abnormality of the spine.
Peripheral Vascular: Pulses were palpated in the following areas with bilateral measurement of +2: radial, ulnar, brachial, femoral, popliteal, posterior tibialis, and dorsalis pedis. Capillary refill is less than 1 second in the fingers and toes.
Neurological: Primitive reflexes noted bilaterally with equal intensity including rooting reflex, sucking reflex, palmar grasp, plantar grasp, asymmetric tonic neck inducing a fencer position, moro reflex inducing abduction and flexion, and a ventral suspension reflex inducing an attempt to raise head and legs.
Assessment: 6-day-old neonate girl that has no acute signs of distress, illnesses, congenital abnormalities, or developmental deficits. The child is on the border of being considered small for gestational age according to height and weight percentile.
Plan: Labs: None
Treatment: No action due to child being healthy, feeding and sleeping normally, and no illness or developmental deficits.
Umbilical Cord Stump/Bathing Baby- Parents are encouraged to not forcefully remove umbilical cord stump, and continue to keep it clean and dry with appropriate attention. Parents are educated that the stump will eventually fall off at 10-21 days and to only bathe the child with sponge bath until it does. When they are able to bathe the baby in the tub they should ensure the water is not too hot (turn down hot water heater to no higher than 120 degrees F), and can check with an inexpensive thermometer that are parent friendly indicating a safe temperature. It is suggested that 2-3 times a week is adequate before the child starts crawling as long as they are providing adequate cleansing during diaper changes and after feedings. Parents are educated to never leave the baby unattended while bathing. They are told it is best to try an unscented, mild baby cleanser such as Dove or Neutrogena and to use baby shampoo.
Nutrition- The parents are educated that the baby’s daily nutritional intake at present time is adequate. However, any changes in feeding or keeping the formula in is of significant concern, and should be monitored closely. Also, educated that the child’s daily caloric requirements will change with age as presented below.
Recommended Daily Allowance (kcal/kg/day)
Parents are educated on signs and symptoms of formula intolerance including chronic diarrhea, bloody stools, atopic dermatitis, wheezing and anaphylaxis. Parents are told that spit ups are normal for up to 6 months if the child is continuing to gain weight at the appropriate rate, but this is not to be confused with actual vomiting. No solid foods should be introduced to the child until 4-6 months, and cues of when child is ready for solid foods are the child’s ability to sit, lean forward, loss of extrusion reflex, indicate fullness (turn head away), feeds every two hours, double their birth weight, and drinks more than 32oz per day. When introducing solid foods single ingredient foods should be primary, and no more than one food introduced per week. Infant cereals are a good first choice. No common food allergens such as soy, peanuts, egg whites, or shellfish should be introduced before the first year. No peanuts, raw fruit, popcorn, candy, hot dogs, or other potentially choke-inducing foods should be presented before the age of two. Constant attention is paramount while the child is feeding to prevent aspiration and choking. Adding liquids to the child’s diet is commonly misconceived. The child should not be introduced to juices until they able to drink from a cup, and no more than two 4oz servings per day should be given to avoid malnutrition, diarrhea, and dental carries. Bottled water generally lacks fluoride and is not necessarily safe as assumed. Whole milk can be added at 1 year, and low fat milk no earlier than 2 years old. At 4-6 months of age iron should be added to the diet, and iron fortified infant cereal is a good source. Vitamin D supplementation may be considered at 4-6 months if the child is exposed to low levels of sunlight. Fluoride supplementation may be considered from 6 months of age to 3 years if the water supply has less than 0.3-ppm fluoride.
3. Development- Parents are educated on appropriate developmental milestones to look out for as seen in the table below. Parents are told that each visit the PCP will evaluate these, and it is important to be monitoring for as the child matures.
Raises head, tight grasp, alerts to sound, regards face
Lifts chest, no longer clenches fist, smiles socially, turns head towards sounds
Tracts objects 180 degrees, reaches for toys and overshoots, rolls from front to back, begin to babble, laughs, cries in different ways, holds head steady (Double BW 4-6 months)
Sits without support, raking grasp, babbles, responds to name, passes objects from hand to hand, supports weight on legs
Tracts path of falling object, smooth hand to hand transition of objects, pincher grasp, crawls, pulls themselves up, cruises, understands “no”, uses finger to point
Scribbles, walks backward, tower of two blocks, 10-15 words, uses a spoon and cup
Runs, towers of 3 blocks, temper tantrums, says and shakes head “no”
Jump over objects, towers of 7 blocks, two word sentences, parallel play
Broad jump, balances on one foot for 3 seconds, answers questions with words, name a friend, tricycle, draws circle, three word sentences, group play, can undo buttons
Hops on one foot, pick out clothes and dress themselves, draws squares, knows colors, (Height is double length at birth)
Balance on one foot greater than 8 seconds, draws a person with at least 6 parts, define words more easily, puts toothpaste on toothbrush and brushes their own teeth, skips, draws a triangle, knows opposites, plays competitively
4. Health Promotion/Disease Prevention/Anticipatory Guidance- Parents are given an idea of what to expect at the respective ages as seen in the table below.
Birth-1 Year—Parents are educated that this is a period of rapid and crucial growth of the child. The child is not only physically dependent on the parents for food, protection, and cleansing, but rely on them for love and attention to stimulate healthy brain growth. It is paramount for the child to have a nurturing and stimulating environment to reach their potential. The child begins with almost equal distribution of sleep and wakefulness. It is important for the child to sleep on their back to avoid SIDS. As the child gets older and has increasing mobility, the challenge of monitoring and keeping harmful objects out of reach increases. Discussed methods of avoiding foreign body complications. Colic is possible and usually starts around 3 weeks of age, but abates to regular behavior around 3 months. It is important to report immediately if the parent is ever afraid they might hurt or neglect the baby. Mother is also warned about possibility of postpartum depression, and is told to not delay reporting any mood changing symptoms. Parents are told of importance of keeping regular scheduled well child checks, immunizations up to date, and prompt acute care for the child. Rear facing seats in the back seat until the child is at least 20 lbs. and 1 year old.
2-5 Years-- Child’s growth and requirements will begin to slow, but it is still a critical period of the child learning the world. Children increasingly begin to enjoy playing with others and eventually competitively. The child will have increasing ability to function more independently. Toilet training can be done during this period, and parents educated that girls generally learn quicker than boys. Bed-wetting is normal up to 4 years old in girls, and up to 5 years old in boys. While activity is good to establish healthy habits, increased activity demands increased attention from the parent. It is very important to monitor child around any bodies of water or other potentially hazardous areas, such as roads. It is good to establish ground rules with the child about what is okay and what is not. Kids can become picky eaters and it is important to try and provide a well-balanced, healthy diet to establish long-term healthy habits. The parents are told to not let the child dictate the menu, and provide a variety of healthy foods so the child can find which ones they like. Again, immunizations, well child checks, and prompt acute care are critical for the child’s health. However, safety and prevention of accidents is the key for healthy childhood. Injury is the most common cause of death in childhood and adolescent years. So water safety, poison control, motor vehicle restraints, helmets and other preventative measures are paramount. Children greater than 1 year old who weigh between 20-40 lbs. should ride in forward facing child seats in the back of the car.
5-10 Years— Drowning is the second leading cause of unintentional death of children. It is recommended to teach a child how to swim when they are older than four years old. Constant monitoring and safety precautions still have to be in place though when the child is around water. It is good practice to do fire drills and talk about what they would do in case of an emergency. Keep poison control and emergency numbers posted in a commonplace, and talk frequently about safe practice. All firearms should be locked away and impossible for the children to gain access to. Child should ride in booster seat up to 8 years old, or 80 lbs. in weight.
10-15 Years—Children should not sit in the front seat until they are 13 years old and always be wearing a seat belt. This is a time where children begin to seek more independence and it is important to have talks about sexual maturation, peer pressure, and consequences of drugs, alcohol and tobacco. It is important to continue healthy habits of a good well-balanced diet, exercise, and well child check ups.
15-18 Years—Child will now be given ability to drive and added responsibilities with age. It is important to know that accidents and MVAs continue to be major threat of mortality to these patients, and how safe driving and seat belts can save their lives. This age group is also at a higher risk for exposure to drugs, alcohol, and tobacco so they should be counseled daily on the adverse affects both legally and health wise. Should also be counseled on safe sex techniques and healthy practices in relationships. It is important to have a trusting, and open relationship with this age group so they don’t feel isolated or like they have no one to talk to about potentially hazardous practices.
Follow Up:Patient will follow up with primary care provider Dr. **** ***** at two weeks of age to review this note and reevaluate child.
Notes: Well child with developmental exam appropriate for neonate. Child needs to be continuously monitored with height, weight, head circumference, and developmental screening to assure they are meeting appropriate age related milestones and no developmental deficits are present. Note should be sent to child’s primary care provider Dr. **** *****.