This is a 2 day old M/F born at XXX via XXX w/no complications and no medical problems who presents for her initial newborn check-up. Mom and Dad are here with baby this morning and have no concerns presently.
Birth weight: 3.245 kg. Weight today: 3.07 kg. Decline of 5.4%
Breastfeeding q 1.5- 2hrs for 10-40 minutes. Initially had issues w/latch, but no issues currently per mom. Has been cluster feeding but this has improved.
Recommend Vitamin D supplementation- 400 IU per day
2 BM's, sticky black dark green. Have not transitioned to yellow stools at this time
2 wet diapers/day.
SLEEP PATTERN: Recommended Hours (10.5-18 hours) _
Sleeping well in between feedings.
No concerns from parents.
Do you have any concerns about your child's development, behavior, or learning? NO
Has periods of wakefulness , is responsive to parental voice and touch , calms when picked up , fixes briefly on faces or object - follows face to midline, lifts head briefly in prone position
How is the family adjusting to new baby: Doing well, most difficult adjustment is sleep.
Family support available: Extended family coming to visit next week.
How are the parent's feeling: Well, no concerns.
PHYSICAL EXAMINATION: Alert, engaging, pink, no apparent distress, w/strong cry. Well developed. Well nourished.
HEENT: 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: Supple. No significant lymphadenopathy.
CHEST: Clavicle intact
LUNGS: Clear to auscultation with equal breath sounds. No wheezes, rales or rhonchi.
HEART: Regular rate and rhythm; normal S1/S2. No murmur. Femoral pulse 2+ and equal.
ABDOMEN: Soft, nontender, normal bowel sounds. No hepatosplenomegaly. No masses.
Umbilical stump present, black in color.
GENITOURINARY: Normal female. No labial adhesions, bleeding.
ANUS: No fissures or swellings.
SKIN: Blotchy areas of erythema present on chest and upper extremities. Diffuse lanugo covering back. 2x2 cm purple discoloration, consistent w/ dermal melanocytosis, present on gluteal cleft.
EXTREMITIES: No hip clicks noted; symmetric creases and normal range of motion. Ortalani/Barlow Maneuver negative. No foot deformities
NEUROLOGIC: Normal tone. Cranial nerves grossly intact. Motor/sensory grossly normal.
SPINE: Normal curvature with no defects or dimples
ASSESSMENT/PLAN: 2 day old with normal growth and development. Birth weight is down by 5.4%, which is normal, will expect to be at birth weight at 2 weeks. Parents w/no concerns today, will f/u again at 2 weeks.
ANTICIPATORY GUIDANCE: Discussed. Age appropriate handouts given. Contains information on normal infant behaviors, feeding, safety and routine newborn care.
Safety: 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, coping strategies reviewed.
Rest and sleep when baby does. Avoid illness exposure.
Parental concerns reviewed and questions answered:
-Should expect 1 additional wet diaper/day of life until about day 5-6.
-Check axillary or rectal temperature at home if increased fussines, poor feeding, poor tone.
-Should begin to start seeing yellow, seedy stools. Come back to be seen if white, red, or bloody stools seen.
- Baby girls can have withdrawal bleedings which resembles a "mini period." Advised parents this is completely normal.
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