Exam (elaborations)
Infant Soap (GI) - Zachary Lafontaine 30 Months
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- Infant Soap - Zachary Lafontaine 30 Months
Infant Soap (GI) - Zachary Lafontaine 30 Months
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Infant Soap (GI) - Zachary Lafontaine 30 MonthsSubjective data
Chief Complain
Mother of 2-month-old male infant is here today for a well visit check.
HPI
Mrs. Lafontaine brought her 2-month-old infant for a well visit check.
Birth information: male infant born via vaginal delivery at 39 weeks.
Length-48.26 cm, Weight-3.28 kg, Head circumference 34.29 cm APGAR 9@ 1 min, 10 @ 5
min. There were no birth complications. Here today accompanied by his mother.
Medications: Currently not taking any medications, No known medication allergies
Nutrition: Breastfeed 2 to 3 times during the day and 3-4 at night so about 5-7 feeds/day for
about 10 min each breast. She states that her schedule varies by days due to her school
schedule.
Elimination: Spitting-minimal, 5-6 wet diapers a day, usually 3 times or less than that for
bowel movement per day soft, mustard yellow in color.
Sleep: Sleeping about 16 hours on Mon-Wed-Fri, Unknown number of hours of sleep on
Tuesday and Thursday as her mother cares for Zachary as her mom gives him one more nap
on these days while she is at school. He does wake up more frequently at night on Tuesday
and Thursdays.
Development and behavior: Mother reports that Zachary smiles, tracks objects with his
eyes, coos, turns to noises and familiar sounds. Able to lift his head when on his tummy.
Safety: Car seat is rear facing in the back seat, she states that Zachary sleeps on his back in
the bassinet or his cradleboard in her bedroom. Smoke alarms controlled regularly. No
exposure to cigarette smoke. Her mother is taking care of Zachary so no daycare or babysitter.
This study source was downloaded by 100000870127142 from CourseHero.com on 12-06-2023 19:39:45 GMT -06:00
https://www.coursehero.com/file/203121509/Infant-SOAP-notesdocx/
, Maternal Health: Reports a very busy schedule. Attends school two days a week and her
mother help care for Zachary when she is at school. Reports she does consume a lot of
nutritious calories, nuts, grains, proteins and drinks plenty of water. Does report insufficient
sleep. Reported breasts feel full before feeding and don’t always feel empty after feeding.
Denies any breast leaking. She denies felling depressed.
Objective data
Vital signs: Length=55.2 cm, Weight=4.39 kg, Head circumference=38.1 cm, Temp=36.2C,
HR= 132/min, RR=36 breaths/min
Growth chart: Infant’s head circumference growth is between 5th and 95th percentile and
curve maintained. Weight and length growth are between 5th and 95th percentile and growth
curve maintained.
General: Infant in mother’s arms, calm and alert.
HEENT: Head: during inspection head is symmetrical with no deformity and thin hair with
uniform distribution. Palpation: Anterior fontanelle is diamond shaped, soft, flat
approximately 2-3 cm in width and 3-4 cm in length., Posterior fontanelle is triangle shaped
0.5-1 cm in size soft and flat.
Eyes: open spontaneously, pupils round PERRL, lens clear, no opacity present, red reflex
present, equal color bilaterally. Follows objects in both directions.
Ears: ears appropriately aligned with external canthus of eyes bilaterally. Palpable fissures,
pinna flexible, lobe formed appropriately, turns head towards sounds.
Nose: Equal airflow noted on the opposite side with manual occlusion of each nares. Nares
patent, pink with thin white mucus present.
This study source was downloaded by 100000870127142 from CourseHero.com on 12-06-2023 19:39:45 GMT -06:00
https://www.coursehero.com/file/203121509/Infant-SOAP-notesdocx/
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