IHUMAN CASE WEEK # 4 | 3 DAY OLD INFACT | REASON FOR
ENCOUNTER WELL VISIT | LATEST EXAM UPDATE
i-Human Case Study
,Patient: 3-Day-Old Infant
Reason for Encounter: Well Visit (Routine Newborn Check)
Course/Class: [insert if needed]
Section Details
3-day-old infant brought for routine newborn visit. Feeding
History of
every 2–3 hrs, latching well. 4–6 wet diapers, 3 stools in last
Present Illness
24 hrs. Parents report mild yellowing of eyes/skin but
(HPI)
otherwise feeding and behavior normal.
Full-term vaginal delivery, 39 weeks. APGAR 8 and 9. Birth
Past Medical weight 3.3 kg. Current weight 3.2 kg (≈3% loss, normal).
History (PMH) No NICU admission. No complications during pregnancy or
delivery.
No family history of congenital disorders, metabolic disease,
Family & Social or neonatal deaths. Infant lives with parents in a non-
History smoking household. Safe sleep and clean environment
confirmed.
- General: Well-appearing, alert.
- Skin: Mild jaundice on face/upper chest.
- HEENT: Fontanelles open/flat, red reflex present.
- Chest/Lungs: Clear, no distress.
Physical - Cardiac: Regular rhythm, no murmurs, strong femoral
Examination pulses.
- Abdomen: Soft, no organomegaly, umbilical stump clean.
- Neuro: Normal tone, reflexes (Moro, suck, grasp) intact.
- Anthropometrics: Length 51 cm, Weight 3.2 kg, Head
circumference 35 cm.
1. Normal well newborn
2. Physiologic jaundice (common at 2–5 days)
Differential
3. Breastfeeding jaundice (if poor feeding; less likely here)
Diagnosis
4. Pathologic jaundice (unlikely – not present in first 24 hrs,
infant otherwise well)
, Section Details
- Not required for routine well visit.
Diagnostic
- If jaundice worsens: Total serum bilirubin, Coombs test,
Workup
blood type.
- Reassure parents: infant is healthy and growing normally.
- Feeding: Encourage breastfeeding q2–3 hrs.
- Hydration: Monitor wet diapers/stools.
Management - Jaundice: Monitor progression; intervene only if bilirubin
Plan rises significantly.
- Parent Education: Safe sleep, car seat safety, hand hygiene,
signs of illness (fever >38°C, poor feeding, lethargy,
worsening jaundice).
- Recheck at 2 weeks for weight and feeding progress.
- Daily home monitoring by parents for feeding adequacy,
Monitoring & diaper count, jaundice changes.
Follow-up - Seek immediate care if red-flag symptoms develop.
1. History of Present Illness (HPI)
• Reason for Visit: 3-day-old infant brought in by parents for a routine
check-up.
• Feeding: Breastfeeding every 2–3 hours; latching well. Occasional spit-
ups but no vomiting.
• Elimination: 4–6 wet diapers in last 24 hrs, 3 yellow/green stools.
• Behavior: Alert when awake, sleeps between feeds. Normal crying
pattern.
• Concerns from Parents: Mild jaundice noticed on skin/eyes, but baby is
feeding and active.
ENCOUNTER WELL VISIT | LATEST EXAM UPDATE
i-Human Case Study
,Patient: 3-Day-Old Infant
Reason for Encounter: Well Visit (Routine Newborn Check)
Course/Class: [insert if needed]
Section Details
3-day-old infant brought for routine newborn visit. Feeding
History of
every 2–3 hrs, latching well. 4–6 wet diapers, 3 stools in last
Present Illness
24 hrs. Parents report mild yellowing of eyes/skin but
(HPI)
otherwise feeding and behavior normal.
Full-term vaginal delivery, 39 weeks. APGAR 8 and 9. Birth
Past Medical weight 3.3 kg. Current weight 3.2 kg (≈3% loss, normal).
History (PMH) No NICU admission. No complications during pregnancy or
delivery.
No family history of congenital disorders, metabolic disease,
Family & Social or neonatal deaths. Infant lives with parents in a non-
History smoking household. Safe sleep and clean environment
confirmed.
- General: Well-appearing, alert.
- Skin: Mild jaundice on face/upper chest.
- HEENT: Fontanelles open/flat, red reflex present.
- Chest/Lungs: Clear, no distress.
Physical - Cardiac: Regular rhythm, no murmurs, strong femoral
Examination pulses.
- Abdomen: Soft, no organomegaly, umbilical stump clean.
- Neuro: Normal tone, reflexes (Moro, suck, grasp) intact.
- Anthropometrics: Length 51 cm, Weight 3.2 kg, Head
circumference 35 cm.
1. Normal well newborn
2. Physiologic jaundice (common at 2–5 days)
Differential
3. Breastfeeding jaundice (if poor feeding; less likely here)
Diagnosis
4. Pathologic jaundice (unlikely – not present in first 24 hrs,
infant otherwise well)
, Section Details
- Not required for routine well visit.
Diagnostic
- If jaundice worsens: Total serum bilirubin, Coombs test,
Workup
blood type.
- Reassure parents: infant is healthy and growing normally.
- Feeding: Encourage breastfeeding q2–3 hrs.
- Hydration: Monitor wet diapers/stools.
Management - Jaundice: Monitor progression; intervene only if bilirubin
Plan rises significantly.
- Parent Education: Safe sleep, car seat safety, hand hygiene,
signs of illness (fever >38°C, poor feeding, lethargy,
worsening jaundice).
- Recheck at 2 weeks for weight and feeding progress.
- Daily home monitoring by parents for feeding adequacy,
Monitoring & diaper count, jaundice changes.
Follow-up - Seek immediate care if red-flag symptoms develop.
1. History of Present Illness (HPI)
• Reason for Visit: 3-day-old infant brought in by parents for a routine
check-up.
• Feeding: Breastfeeding every 2–3 hours; latching well. Occasional spit-
ups but no vomiting.
• Elimination: 4–6 wet diapers in last 24 hrs, 3 yellow/green stools.
• Behavior: Alert when awake, sleeps between feeds. Normal crying
pattern.
• Concerns from Parents: Mild jaundice noticed on skin/eyes, but baby is
feeding and active.
