Exam (elaborations)
Comprehensive Infant Well-Visit SOAP Note, Case of Zachary Lafontaine
- Course
- Business
- Institution
- George Mason University
Comprehensive Infant Well-Visit SOAP Note, Case of Zachary Lafontaine
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lOMoARcPSD|14985576Assessment of the Infant SOAP note
Subjective
Identifying data and Reliability
Ms. L presents to the clinic with her two-month-old son Zachary (ZF) and agrees to be
the historian today for her son’s physical assessment.
Chief Complaint
Ms. L reports bringing ZF in for a wellness visit, “It was hard to work it into our
schedule, but I know it’s important.”
HPI (History of Present illness)
Ms. L reports breastfeeding ZF. She reports not using formula and is strongly adamant
about breastfeeding ZF stating that formula would be a last resort for her. She admits having a
hard time finding enough time to breastfeed due to her busy schedule. When asked about
pumping, she reports that she does not have a pump at home and can not afford it. She reports
feeding ZF 2-3 hours during the day and 3-4 times at night but that she does not always manage
it. She reports giving him 20-minute feeds with ZF feeding 10 minutes on each breast. She
reports her breast feeling full before feeding but do not always feel empty after feeding. She
reports feeding ZF at different times throughout the day depending on what her schedule is like.
She reports feeling overwhelmed with keeping up on his feeding schedule and with breastfeeding
due to it being something that is new to her. She reports that ZF is able to latch well on her
breasts. She also denies breast and nipple pain or frequent breast leaking.
PMH/ Medications/ Allergies
None
Pertinent Family History, Social History, and other Subjective data if relevant
, lOMoARcPSD|14985576
Two-month-old male in today for wellness check. Infant born via vaginal delivery at 39
weeks gestation. Length 19 inches and weight 7lbs 4oz. APGAR 9@1 min 10 @ 5 min. There
were no birth complications. Here today accompanied by mother. Mother is the primary
caregiver but does receive some help from her mother when she is at school or at work. She
works at a campus bookstore full-time and is in school for her Bachelor of Nursing degree in
which she goes to classes about 2 nights out of the week. She reports feeling “overwhelmed”
and reports it “being a lot”. She has not been getting an adequate amount of sleep. She reports
that she tries to eat a healthy diet and stay hydrated by drinking plenty of water for breastfeeding.
She reports that she also eats extra for breastfeeding and that her diet mostly consists of mostly
snacks on top of her normal meals such as trail mix, fruit, nuts, and good proteins. She reports
minimal support network outside of her family and that the baby’s father is not in the picture. ZF
sleeps about 16 hours a day on Monday, Wednesday, and Friday but she is unsure how much he
sleeps on Tuesdays and Thursdays as she is at class on those days and her mom watches ZF. She
reports her mom gives him an extra nap on those days. She reports that cries more at night on
Tuesdays and Thursdays on her class days and has a lot of trouble sleeping on those days. Ms. L
reports that ZF sleeps in a bassinet at night or sometimes in his cradleboard and that he is always
swaddled and on his back. She keeps the bassinet in her room and close to her, but he does not
sleep in the bed with her. She reports that he is a happy baby and that he coos, tracks objects with
his eyes, turns to noises and familiar sounds, and can lift his head when on his tummy. She also
reports that he has about 5-6 wet diapers a day and usually 3 bowel movements a day that are
soft, and mustard yellow in nature.
Objective
ZF Vitals
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