6 week check

[Patient name] attended today with Mum for a 6-week check. Baby [Patient name] is a full-term baby, born at 39 weeks gestation via spontaneous vaginal delivery. There were no complications during the pregnancy or delivery. [He/She] was born with Apgar scores of 9 at 1 minute and 10 at 5 minutes. [His/Her] birth weight was 3.2 kg, length 50 cm, head circumference 35 cm. [He/She] had no relevant findings at birth. [His/Her] newborn screening results were normal. [He/She] had no relevant issues in the first few days of life. **Progress** Overall, [patient name]'s progress is excellent. [Patient name] is exclusively breastfed and takes 120ml every 3-4 hours for 15-20 minutes. There are no relevant feeding issues. The bowel motions are yellow, seedy, and occur 3-4 times per day. There has been no respiratory issues, there has not been any relevant negatives, and [he/she] is alert and responsive. [Patient name] has smiled responsively and is starting to coo. There has been no other relevant issues and no relevant interventions/changes made. [He/She] is feeding well and is alert and responsive. **Exam** Growth is appropriate with: - Weight: 4.5 kg (50th percentile, 200 g/week) - Length: 56 cm (50th percentile) - Head Circumference: 38 cm (50th percentile) Full physical examination of [patient name] is normal. Relevant skin findings are clear. The fontanelle is open and flat, muscle tone is normal, and the red reflex was present bilaterally. The pulses are strong and equal, heart sounds are normal, the chest is clear, abdomen is soft and non-tender, genitalia are normal, and the hips are stable. No other relevant examination findings. **Plan** 1. Discussed safe sleeping practices. 2. Reviewed feeding – continue breastfeeding on demand. 3. Provided a handout on infant development. 4. Provided resources for local breastfeeding support groups. 5. Advised on vitamin D supplementation. 6. Follow up in 6 weeks for routine immunisations. "I would be delighted to review [patient name] if the future need arose."