Newborn visit (2-3 days old)
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. DIET: 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 ELIMINATION: 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. BEHAVIOR/TEMPERAMENT: No concerns from parents. DEVELOPMENT: 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 SOCIAL: 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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