1-Week-Old Routine Check-Up
Presents for a 1-week well-child check-up
Accompanied by:
Age: days, Gestational age: months
Birth length: cm
Birth weight: g
Birth head circumference: cm
Discharge weight: g
Past medical history:
Family history:
Known risk factors:
Current symptoms or caregiver concerns:
NUTRITION:
Breastfeeding: , feeds daily
Vitamin D 400 IU/day (if breastfeeding):
Formula feeding (150 mL (5 oz)/kg/day): daily, type:
Regurgitation:
Choking during feeding:
Iron supplement (if prematurity):
Stool pattern and urine output:
EDUCATION AND ADVICE:
Sleep: total hrs per day
Sleep habits:
Living with: ,
Parenting/bonding:
Family conflict/stress:
Parental fatigue/postpartum depression:
Difficulty making ends meet or food insecurity:
High-risk infants/assess home visit need:
Second hand smoke exposure:
Complementary/alternative medicine:
Counseling:
- Falls (stairs, change table)
- Carbon monoxide/smoke detectors
- Choking/safe toys
- Poison prevention (poison control center)
- Car seat facing back
- Burn prevention
- Carbon monoxide/smoke detectors
- Hot water <49°C/bath safety
- Limit sun exposure
- Supervised tummy time while awake
- Safe sleep (room sharing, avoid bed sharing, crib safety)
- No OTC cough/cold medicine
- Temperature control and overdressing
- Fever advice
DEVELOPMENT:
Sucks well on nipple:
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Metrics: length: cm - th perc, weight: kg - th perc, head circ: cm - th perc
Head: fontanelles ,
Eyes: conjunctiva/sclera , lids/lashes , , extraocular movements , red reflex , corneal light reflex , fix and follow test
Ears: tympanic membranes , auditory canal on , hearing
Nose: , , discharge ,
Throat: , ,
Neck: , , , , , c-spine
Heart: , ,
Lungs: , ,
Abdomen: , , ,
Genitourinary: external genitalia , testes , penis , Tanner stage
Extremities: , , , , Barlow , Ortolani , , cap refill sec
Skin: on
Musculoskeletal: joints ,
Neurologic: cranial nerves , overall motricity , muscle tone , gait , reflexes
Mental status: , , reactive to
ASSESSMENT:
DDx: transient tachypnea of the newborn, neonatal jaundice, feeding difficulties, intrauterine growth restriction, congenital infections, metabolic disorders, congenital heart disease, neonatal sepsis, hypoglycemia, hypocalcemia, birth trauma, neonatal abstinence syndrome, respiratory distress syndrome, gastroesophageal reflux, anemia, hemolytic disease of the newborn, genetic disorders, structural abnormalities, neurological disorders, environmental exposure concerns, attachment issues, behavioral issues
PLAN:
Investigations:
- Hearing screening if not done at birth
- Vision screening if at risk
- Hemoglobinopathy screen (if at risk)
Treatments:
- Caregiver questions answered
- Iron supplementation if premature
- Vitamin D supplementation if breastfeeding or premature
- Immunizations: If HBsAg-positive parent/sibling Hep B vaccine #1
Further care:
- Referral to resources and support for parents if needed
- Follow-up in
EXAM: ASSESSMENT: PLAN: