2-week visit H&P
CC: [text name="variable_1" default="2-week visit"] Subjective * HPI: [textarea name="variable_2" default="This is a 2-week-old M/F born via VAG/C-SEC w/no complications and no medical problems who presents for her initial newborn check-up. Mom/Dad are here with baby this morning and have no concerns presently. Patient is awake, sitting quietly in carseat, no signs of respiratory ditress/awake, being held by mom and crying."] [textarea name="variable_3" default="* First visit: Has done well over the past 2-weeks. Alert to sights and sounds. Coos and smiles. Turns to sound. Holds object. Recognizes face. No concerns regarding hearing. No problems with urine or stool. Sleeps on back. Usual sleep pattern."] Nutrition: [textarea name="variable_4" default="nursing every 2-3 hours / formula every 2-3 hours / No concerns regarding feeding / Nutrition includes 6-8 oz / feeding, 4-6 feedings/ 24 hours (94-130 kcal/kg/day). / Nutrition includes 4-5 oz / feeding, q3-4 6-8 feedings / 24 hours"] Stools: [textarea name="variable_5" default="1-5 yellow, pasty, but formed stools/24 hours"] Void: [textarea name="variable_6" default="q1-3 hours/with each feeding and diaper change"] * ROS SKIN: [textarea name="variable_7" default="denies rashes or lesions/ white dots on baby’s nose/ red dots on baby’s face / newborn rash"] HEENT: [textarea name="variable_8" default="Eyes: denies redness or eye drainage. Ears: denies ear redness or drainage; hearing screen passed in both ears while in hospital/hearing screen referred on left/right ear, follow-up appointment scheduled for next friday. Nose/Sinuses: c/o occasional nasal congestion"] NECK: [textarea name="variable_9" default="denies lumps or masses"] HEART: [textarea name="variable_10" default="congenital cardiac defect screening passed in hospital"] LUNGS: [textarea name="variable_11" default="denies wheezing or SOB"] GASTROINTESTINAL: [textarea name="variable_12" default="denies gassiness or constipation"] GENITOURINARY: [textarea name="variable_12" default="Normal female/male. No labial adhesions, bleeding /no swelling or redness/circumcised at hospital /denies blood or discharge"] RECTUM: [textarea name="variable_13" default="denies bleeding or swelling"] MUSCULOSKELETAL: [textarea name="variable_14" default="denies abnormalities or concerns in baby’s movements"] NEURO: [textarea name="variable_15" default="denies abnormal, jerky movements; reports (+) moro reflex"] Objective * Vitals: HR [text name="variable_16" default=" "], RR [text name="variable_17" default=" "] Wt [text name="variable_18" default=" lb, oz (xx % percentile)"] Length: [text name="variable_19" default=" in. (xx % percentile)"] Head circumference: [text name="variable_20" default=" cm. (xx % percentile)"] Birth weight: [text name="variable_21" default=" lb, oz"] Discharge weight: [text name="variable_22" default="Wt lb, oz"] * Physical Exam PHYSICAL EXAMINATION: [textarea name="variable_23" default="Alert, engaging, pink, no apparent distress, w/strong cry. Well developed. Well nourished."] HEENT: [textarea name="variable_24" default="Head: Anterior fontanelle soft, flat. Sutures apposed. Normocephalic. Eyes: Bilateral RR. Conjunctivae pink without discharge. Nose: Clear. No discharge. Mouth/throat: No oral lesions. The pharynx is without exudates or erythema."] NECK: [textarea name="variable_25" default="Supple. No significant lymphadenopathy."] CHEST: [textarea name="variable_26" default="Clavicle intact"] LUNGS: [textarea name="variable_27" default="Clear to auscultation with equal breath sounds. No wheezes, rales or rhonchi."] HEART: [textarea name="variable_28" default="Regular rate and rhythm; normal S1/S2. No murmur. Femoral pulse 2+ and equal."] ABDOMEN: [textarea name="variable_29" default="Soft, nontender, normal bowel sounds. No hepatosplenomegaly. No masses. Umbilical stump present, black in color."] GENITOURINARY: [textarea name="variable_30" default="Normal female/male. No labial adhesions, bleeding/ Testes descended bilaterally. No hernia present."] ANUS: [textarea name="variable_31" default="No fissures, swellings, sacral dimple, or sacral tuft"] SKIN: [textarea name="variable_32" default="Good turgor and without lesions."] EXTREMITIES: [textarea name="variable_33" default="No hip clicks noted; symmetric creases and normal range of motion. Ortalani/Barlow Maneuver negative. No foot deformities"] NEUROLOGIC: [textarea name="variable_34" default="Normal tone. Cranial nerves grossly intact. Motor/sensory grossly normal."] SPINE: [textarea name="variable_35" default="Normal curvature with no defects or dimples"] PREVENTATIVE HEALTH * Immunizations: [textarea name="variable_36" default="HepB given at hospital."] * Diagnostics: [textarea name="variable_37" default="2-week Newborn screening performed today"] ASSESSMENT/PLAN [textarea name="variable_38" default="ENCNTR FOR ROUTINE CHILD HEALTH EXAM W/O ABNORMAL FINDINGS * Injury prevention and health promotion issues discussed. Discussed well-visit appointment schedule and immunization schedule. * No immunizations given today. * Provided education on various topics of safety including using rear-facing car seats in back seat, never in front seat of vehicle with air bag, keep home/vehicle smoke free, never shake or hit a baby, and avoid illness exposure. Discussed coping strategies and resting and sleeping when baby does."] [textarea name="variable_39" default="HEALTH EXAMINATION FOR NEWBORN 8 TO 28 DAYS OLD * Examination revealed no concerning SSs. Next follow-up for 2-month visit and immunizations."]Follow up: [text name="variable_40" default="2-month visit [wellness & immunizations"]
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