2-Week-Old Routine Check-Up
Presents for a 2-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:
Medications:
Allergies:
Family history:
Known risk factors:
Current symptoms or caregiver concerns:
NUTRITION:
Breastfeeding: , feeds daily
Vitamin D 400 IU/day (if breastfeeding):
Formula feeding/Preparation (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
- Hot water <49°C/bath safety
- Safe sleep (room sharing, avoid bed sharing, crib safety)
- Limit sun exposure
- Supervised tummy time while awake
- Water not required if exclusive breastfeeding
- 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, inadequate weight gain, infection (e.g., sepsis, urinary tract infection), congenital heart disease, metabolic disorders, gastroesophageal reflux, anatomical anomalies (e.g., cleft lip/palate), neonatal abstinence syndrome, maternal medication effects, breast milk jaundice, dehydration, hypoglycemia, inborn errors of metabolism, hemolytic disease of the newborn, immune or non-immune hydrops, endocrine disorders (e.g., congenital hypothyroidism), genetic disorders, neurological concerns (e.g., hypotonia, seizures), 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: