Newborn Evaluations

Please evaluate the subjective and objective information provided to you in the file below.
The first part of the discussion board is to identify all pertinent positive and negative information.
Would there be any other information you would want to obtain?
Then create a differential diagnosis list with at least 3 possibly actual diagnosis based on your findings.
Second part is to create a plan utilizing clinical practice guidelines for the priority diagnosis.
What state or federal resources are available to these parents?
What health promotion recommendations may you want to consider?
Be sure to include APA in-text citations and provide full reference citation at the end of the discussion.

C.C. 3-day old checkup
HPI: Mother and Father present to clinic in Central Pennsylvania with their 3-day old son. 3 day old. M
was born at home at 38 weeks’ gestation. Since his birth, mother has noticed poor feeding habits, very
few sweet-smelling wet diapers and sleeping more. This was their 4th home delivery, 3 living children
without any developmental or medical concerns. Have never experienced this behavior with their other
children who are now 5, 4, 1.
PMH: Born at 38 weeks’ gestation vaginally at home. There were no complications at birth. There were
no complications throughout the pregnancy. The infant’s mother denies tobacco use, drug use, or
alcohol use during pregnancy. The infant is breastfed. The siblings are not vaccinated.
Allergies: No known drug allergies
Medications: None
Social History: The infant lives with his mother, father, siblings and maternal grandparents. Live on a
farm in Lancaster County. Mennonite. Mother stays at home with children and father works on the
family farm/wood mill. The infant is not exposed to tobacco smoke.
Family History: Mother and father deny any significant medical history. Siblings have no significant
medical history and are not up to date on immunizations.
Review of Systems
General: Mother denies unexplained fevers. Concerned about increase sleep, weak suck and poor eating
Skin: The infant’s mother denies any rash or lesions.
Head: Mother denies any trauma/forceps used in birth.
ENT: Mother denies any concerns with the infant’s ears, nose, or throat.
Neck: Mother denies any concerns with neck.
CV: The infant’s mother denies any cyanotic spells or a discoloration of the skin.
Lungs: The infant’s mother denies any cough, congestion, wheezing, or difficulty breathing.
GI: Mother reports 1 bowel movements per day, dark in color. Denies meconium during birth.
GU: Negative for diaper rash. Mother has reported decrease number of wet diapers and has noticed a
sweet odor when changing cloth diaper.
VS: Temperature: 99.7 F, HR: 161, RR: 52 Ht: 21 in, Wt.: 6lbs, 4.6 oz, HC: 46.1 cm
General: Appears lethargic, sunken eyes, pale skin. Laying on table in “fencing” pose.
Skin: No evidence of rash or lesions.
Head: Normocephalic.
Eyes: The lids and conjunctiva are normal. Pupils are irises are normal fundoscopic exam reveals red
reflex present bilaterally.
ENT: Normal external ears and nose. Normal external auditory canals and tympanic membranes. Tip of
otoscope sweet smell once removed from ear. Oropharynx: normal mucosa, palate, and posterior
Neck: Supple, no adenopathy.
CV: Tachycardic and rhythm. Faint murmur noted. Femoral pulse 2+ bilaterally.
Lungs: Increase respirations with nasal flaring, lungs clear bilaterally.
Abd: Hypoactive bowel sounds. No masses or tenderness or organomegaly observed.
GU: Penis: normal uncircumcised male. Testes descended with no inguinal hernia noted.
MSK: Poor tone and muscle strength. Negative for “hip click”.

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