Management Plan by Shanice Shondalei Stephens on case i-
Human Case Week #4
encounter for routine child health examination without abnormal
findings
Patient: 3-day-old newborn, well visit
SUBJECTIVE – 15 pts
Chief Complaint: Newborn well visit
HPI (OLDCART):
• Onset: Since birth
• Location: General health
• Duration: 3 days old
• Characteristics: Healthy term newborn, exclusively breastfed, feeds every 2–3 hours, good latch. Passed
meconium within 24 hrs; now yellow stools. No jaundice, color changes, abnormal movements, respiratory
distress, or poor feeding.
• Aggravating/Relieving Factors: None
• Treatment Tried: None
• Severity: Mild, physiologic weight loss expected
Pertinent Positives: Good feeding, adequate stools, active, circumcision healing well, bonding appropriate.
Pertinent Negatives: No vomiting, fatigue, tachypnea, sweating during feeds, color changes, abnormal movements,
or maternal depression.
Allergies: None
Past Medical History: Healthy term newborn
Family History:
• Mother: 29, healthy
• Father: 31, healthy
• Sibling: 3 yo, healthy
• Maternal grandmother: 61 yo, hyperlipidemia
• Maternal grandfather: 66 yo, MI at 65, diabetes, HTN
• Paternal grandmother: 62 yo, lupus
• Paternal grandfather: 63 yo, osteoarthritis
• No congenital or metabolic disorders in family
Medications:
• Vitamin D drops 400 IU PO daily
Social History:
• Lives with mother, father, and older brother
• Smoke-free home, child locks and baby gates in place
• Rides in rear-facing car seat
OBJECTIVE – 15 pts
Vital Signs:
• Height: 20 in; Weight: 7 lbs; BMI: 12.3
, • Temp: 98.3°F (oral)
• HR: 145 bpm, regular, normal strength
• BP: L 73/56, R 78/54 → normotensive, normal pulse pressure
• RR: 45/min, regular, unlabored
• SpO₂: 98%
Physical Exam:
• General: Alert, active, moves all extremities spontaneously
• HEENT: AFOSF; no scalp hematoma. Pupils equal/reactive; red reflex present. EOMI. Ears symmetric, no
erythema/drainage; TMs pearly gray. Nares patent, septum midline. Oral mucosa pink, intact palate, normal
frenulum. Rooting/suck reflex intact.
• Neck: Supple; tonic reflex intact
• Cardiovascular: RRR, no murmurs, gallops, or thrills
• Respiratory: Lungs clear bilaterally; no wheezing, stridor, or retractions
• Abdomen: Soft, non-tender; bowel sounds ×4. Umbilical cord drying, no discharge or erythema
• GU/Rectal: Circumcised penis healing well; testes descended bilaterally. Rectum normal; no rashes or lesions
• Musculoskeletal: Full ROM; negative Ortolani/Barlow. Mild tibial torsion and genu varum. Stepping reflex
intact
• Neurological: Moro, Babinski, plantar, and grasp reflexes intact (Modrell & Tadi, 2023)
• Skin: Warm, dry, no lesions, rashes, or jaundice
Diagnostics/Labs/Screening:
• Newborn metabolic screen pending (performed within 24–48 hours) (Perez & Mendez, 2023)
• Hearing screen passed prior to discharge
• Initial total bilirubin >24 hrs: 6 mg/dL; follow-up fractionated bilirubin ordered
ASSESSMENT – 15 pts
Primary Diagnosis:
• Well child check, newborn 0–28 days – Z00.110
Rationale: Healthy term newborn with appropriate weight loss, feeding effectively, normal elimination, no signs
of jaundice or infection, and stable vitals. Circumcision healing appropriately. Follows AAP Bright Futures
newborn visit recommendations.
Differential Diagnoses:
1. Neonatal jaundice (P59.9) – Monitored with follow-up fractionated bilirubin; initial level 6 mg/dL
2. Feeding difficulty in newborn (P92.9) – Ruled out; feeds well, no fatigue or distress
3. Neonatal infection (P36.9) – Unlikely; no fever, poor feeding, lethargy, or abnormal exam findings
Newborn Screening & Reflex Testing:
• Routine Care: Comprehensive assessment within 24–48 hours include vitals, growth measures, reflexes,
metabolic and hearing screens, and jaundice evaluation (Perez & Mendez, 2023)
• Screening: Detects metabolic, endocrine, hemoglobinopathies, and other treatable disorders; early detection
allows timely interventions (CDC, 2022)
• Reflexes: Primitive reflexes (rooting, suck, Moro, grasp, Babinski) intact, indicating normal CNS development
(Modrell & Tadi, 2023)
MEDICATIONS – 10 pts
• Vitamin D drops 400 IU PO daily
- Sig: Take 1 drop PO daily
- Disp: 1 bottle (30-day supply), refills ×5 PLAN
– 15 pts
Screening Tools:
• Newborn metabolic screen (pending)
• Hearing screen completed
Referrals:
Human Case Week #4
encounter for routine child health examination without abnormal
findings
Patient: 3-day-old newborn, well visit
SUBJECTIVE – 15 pts
Chief Complaint: Newborn well visit
HPI (OLDCART):
• Onset: Since birth
• Location: General health
• Duration: 3 days old
• Characteristics: Healthy term newborn, exclusively breastfed, feeds every 2–3 hours, good latch. Passed
meconium within 24 hrs; now yellow stools. No jaundice, color changes, abnormal movements, respiratory
distress, or poor feeding.
• Aggravating/Relieving Factors: None
• Treatment Tried: None
• Severity: Mild, physiologic weight loss expected
Pertinent Positives: Good feeding, adequate stools, active, circumcision healing well, bonding appropriate.
Pertinent Negatives: No vomiting, fatigue, tachypnea, sweating during feeds, color changes, abnormal movements,
or maternal depression.
Allergies: None
Past Medical History: Healthy term newborn
Family History:
• Mother: 29, healthy
• Father: 31, healthy
• Sibling: 3 yo, healthy
• Maternal grandmother: 61 yo, hyperlipidemia
• Maternal grandfather: 66 yo, MI at 65, diabetes, HTN
• Paternal grandmother: 62 yo, lupus
• Paternal grandfather: 63 yo, osteoarthritis
• No congenital or metabolic disorders in family
Medications:
• Vitamin D drops 400 IU PO daily
Social History:
• Lives with mother, father, and older brother
• Smoke-free home, child locks and baby gates in place
• Rides in rear-facing car seat
OBJECTIVE – 15 pts
Vital Signs:
• Height: 20 in; Weight: 7 lbs; BMI: 12.3
, • Temp: 98.3°F (oral)
• HR: 145 bpm, regular, normal strength
• BP: L 73/56, R 78/54 → normotensive, normal pulse pressure
• RR: 45/min, regular, unlabored
• SpO₂: 98%
Physical Exam:
• General: Alert, active, moves all extremities spontaneously
• HEENT: AFOSF; no scalp hematoma. Pupils equal/reactive; red reflex present. EOMI. Ears symmetric, no
erythema/drainage; TMs pearly gray. Nares patent, septum midline. Oral mucosa pink, intact palate, normal
frenulum. Rooting/suck reflex intact.
• Neck: Supple; tonic reflex intact
• Cardiovascular: RRR, no murmurs, gallops, or thrills
• Respiratory: Lungs clear bilaterally; no wheezing, stridor, or retractions
• Abdomen: Soft, non-tender; bowel sounds ×4. Umbilical cord drying, no discharge or erythema
• GU/Rectal: Circumcised penis healing well; testes descended bilaterally. Rectum normal; no rashes or lesions
• Musculoskeletal: Full ROM; negative Ortolani/Barlow. Mild tibial torsion and genu varum. Stepping reflex
intact
• Neurological: Moro, Babinski, plantar, and grasp reflexes intact (Modrell & Tadi, 2023)
• Skin: Warm, dry, no lesions, rashes, or jaundice
Diagnostics/Labs/Screening:
• Newborn metabolic screen pending (performed within 24–48 hours) (Perez & Mendez, 2023)
• Hearing screen passed prior to discharge
• Initial total bilirubin >24 hrs: 6 mg/dL; follow-up fractionated bilirubin ordered
ASSESSMENT – 15 pts
Primary Diagnosis:
• Well child check, newborn 0–28 days – Z00.110
Rationale: Healthy term newborn with appropriate weight loss, feeding effectively, normal elimination, no signs
of jaundice or infection, and stable vitals. Circumcision healing appropriately. Follows AAP Bright Futures
newborn visit recommendations.
Differential Diagnoses:
1. Neonatal jaundice (P59.9) – Monitored with follow-up fractionated bilirubin; initial level 6 mg/dL
2. Feeding difficulty in newborn (P92.9) – Ruled out; feeds well, no fatigue or distress
3. Neonatal infection (P36.9) – Unlikely; no fever, poor feeding, lethargy, or abnormal exam findings
Newborn Screening & Reflex Testing:
• Routine Care: Comprehensive assessment within 24–48 hours include vitals, growth measures, reflexes,
metabolic and hearing screens, and jaundice evaluation (Perez & Mendez, 2023)
• Screening: Detects metabolic, endocrine, hemoglobinopathies, and other treatable disorders; early detection
allows timely interventions (CDC, 2022)
• Reflexes: Primitive reflexes (rooting, suck, Moro, grasp, Babinski) intact, indicating normal CNS development
(Modrell & Tadi, 2023)
MEDICATIONS – 10 pts
• Vitamin D drops 400 IU PO daily
- Sig: Take 1 drop PO daily
- Disp: 1 bottle (30-day supply), refills ×5 PLAN
– 15 pts
Screening Tools:
• Newborn metabolic screen (pending)
• Hearing screen completed
Referrals:
