i-Human Case Study Week 4: Comprehensive Assessment of a 3-Day-Old Infant Routine Evaluation at Outpatient Clinic

Chief Complaint Mother brings her 3-day-old infant for a routine newborn well visit. History of Present Illness (HPI) Mother states the baby is feeding every 2–3 hours, primarily breastfeeding, with occasional expressed breast milk given by bottle. Baby latches well and swallows audibly. Infant has 4 wet diapers and 3 stools in the last 24 hours. She denies fever, vomiting, lethargy, or poor feeding. Perinatal/Birth History - Gestational age: 39 weeks, term - Delivery: Vaginal, spontaneous, uncomplicated - Apgar scores: 8 and 9 - Birth weight: 3.2 kg - No maternal complications during pregnancy. Negative for GBS, HIV, Hep B, or substance use. Family/Social History - Lives with both parents, strong family support. - No smokers in household. - Infant sleeps in a crib, on her back. - Rear-facing car seat used. Review of Systems - General: Active, alert, normal cry. - Nutrition: Breastfeeding well, no issues. - GU: Normal voiding and stooling. - Skin: Mild yellowing of face noted by mother. - Respiratory: No cough, apnea, or cyanosis. - Neuro: Normal tone, reflexes intact. Objective Findings Vitals: HR 130 bpm, RR 42, Temp 98.2°F (axillary), weight 3.0 kg (6% below birth weight). General: Vigorous, strong cry, active. Skin: Warm, mild jaundice to face, no rash. Head/Neck: Anterior fontanelle soft/flat; sutures normal. Eyes: Bilateral red reflex present. ENT: Palate intact; nares patent; good suck. Chest/Lungs: Clear bilaterally, no retractions. Cardiac: Regular rhythm, no murmurs, pulses equal. Abdomen: Soft, nondistended, bowel sounds present; umbilical stump clean. GU: Normal female genitalia; anus patent. MSK: Full ROM, negative Ortolani/Barlow. Neuro: Primitive reflexes (Moro, grasp, rooting, Babinski) intact. Assessment - Healthy 3-day-old term newborn - Normal physiologic weight loss (<10%) - Adequate feeding and elimination - Mild physiologic jaundice - No acute concerns Plan / Evaluation 1. Continue breastfeeding on demand q2–3 hrs. 2. Vitamin D supplementation if exclusively breastfed. 3. Anticipatory guidance: safe sleep (back to sleep), car seat, infection precautions, jaundice monitoring, when to call provider. 4. Confirm results of newborn screen, hearing test, CCHD screen. 5. Immunizations: Hepatitis B #1 received in hospital (verify). 6. Follow-up: Recheck weight and feeding at 2 weeks.