Well child – 0 mo

Sep 7, 2018 • Mark Morgan

categories: Pediatrics

HISTORY:

provided by parent provided by other unobtainable d/t parental anxiety and/or lack of knowledge interpretation provided by family member interpretation provided by MA

Hospital:

Born:

term postterm preterm
BW:

Bilirubin:

unknown NL
Hep B:

maternal Neg maternal Pos maternal Unk vaccine given vaccine not given
Newborn screening:

pending unknown normal
Hearing screening:

passed per parent unknown pending

SPECIAL NEEDS:

none specialty
FAMILY HISTORY:

reviewed Neg
SOCIAL HISTORY:

none child care housing single parent working parent siblings maternal depression
CONCERNS:

none raised questionnaire provided reviewed

REVIEW OF SYSTEMS
General:

doing well, alert to sights and sounds, quiets with comforting
Nutrition:

no concerns breast formula on demand 10-12 per day
Urination:

no concerns 6-8 wet diapers per day
Stooling:

no concerns passed meconium green yellow soft
Sleep:

no concerns crib

DEVELOPMENT:

growth chart provided, discussed, developing well
MILESTONES:

sucks, swallows, breathes easily follows face turns and calms to caregiver voice

EXAM
Appearance:

well-appearing active, interactive strong suck crying easily consoled NWOB moist mucous membranes uncooperative with exam
Skin:

pink, normal turgor no jaundice no bruises erythema toxicum milia
Head:

no skull deformities both fontanelles open & soft swelling
Eyes:

anicteric sclerae, blinks to light, red reflex bil no discharge in corners palpebral exudate
Ears:

normal position, turns to sound
Nose:

nares patent
Mouth:

oral mucosa moist & without lesions, tongue normal in appearance/size & with good movements, normal palate strong suck teeth not present
Throat:

patent pharynx w/o swelling or exudates
Neck:

supple, symmetrical ROM, turns head side to side
Chest:

unlabored respirations, symmetric chest expansion, clavicles nontender & symmetrical, clear and equal breath sounds bilaterally
Heart:

regular rate & rhythm, no murmurs
Abdomen:

soft, nondistended, nontender, no obvious palpable masses, bowel sounds normal umbilicus healing w/o infection
Genitalia:

normal appearance uncircumcised circumcised healing well testes down bilaterally
Extremities:

symmetrical FROM, normal palmar creases, five digits, hips w/ good abduction w/o clicks
Peripheral vascular:

femoral pulses present & equal, normal perfusion
Back:

normal spine no sacral dimpling
Neuro:

normal reflexes, newborn reflexes present & symmetrical, normal & symmetrical tone/strength

LABORATORY/OFFICE DIAGNOSTICS:

none non-specific changes reviewed & discussed with parent normal non-specific changes official report to follow pending

IMMUNIZATION:

none per schedule next visit

OUTSIDE ORDERS/REFERRALS:

none laboratory studies diagnostic studies specialty WIC

DISCUSSED AND/OR HANDOUT GIVEN/OFFERED:

crib safety, back to sleep, no bottle in bed, hand on baby, smoke detectors, hot liquids, smoke-free environment signs of illness feeding, burping, no solids, no honey, no cow milk elimination cord care circumcision care calming techniques

FOLLOW UP:

2 months of age, sooner if concerns arise

Well child – 0 mo

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