Casey Coon COMPREHENSIVE SOAP NOTE 2
1/31/2014
Eli- 24 day old male
S: CC: 3 week Well Visit
HPI: PT presents with Mother for his 3 week well child check
PMH: Eli was born at Faxton-St. Luke’s at 38 weeks 1 day. Mom was induced due to poor
weight gain; she was in labor for 4 hours. He was a vaginal birth and weighed 4lbs 9 oz,
17.5 inches long, head circum 12.25 inches, apgar scores at 1 minute was 9, and 5 minutes
was 9. His discharge weight from the hospital was 4lbs 7oz. Mother’s blood type is B
negative. Passed newborn hearing screen, discharge bilirubin was 8.9. On January 17th
bilirubin was 5.9. Mothers Prenatal Screen: Negative For Antibody Screen, CF Carrier,
Chlamydia, GC, Rubella - immune, VDRLHEPB:
Maternal Birth History: Gravidity: 1, Parity: 1
General Health-Over all he is a healthy male infant
Med/Illness- None
Surg. - None.
Inj/Acc. - None.
Hosp- None.
Transfusions- None.
Psych- None.
Child Disease- None.
Immunization- Had Hepatitis B immunization at birth
Allergies- No known allergies to medications, food, environmental or latex
Meds- will be started on vitamin D supplement this visit
Family History: Everyone is well at this time. No history of SIDS or asthma

Father: Healthy takes no medications.

Mother: Healthy take no medications.
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Maternal Grandparents: unknown, Still living

Paternal Grandparents: unknown, Still living
Social History: Eli lives with Mom and Dad, Mom and Dad do not smoke, no one else
smokes around the infant, infant is at home with Mom, does not attend day care. Mom has
12 weeks off from work and plans on breast feeding the entire time. Ensures good hand
hygiene by all. Mother has no concerns at this time.
Breast feeds well, good latching, wakes to nurse regularly about every 3-4 hours. Both sides
for 10-15 minutes. Mom is not pumping at this time but her breast does not feel full after
feedings. Mom does hear gulping when he nurses.
Eli is voiding well, about 6-8 wet diapers a day, He is having BM’s a couple times a day, they
are yellow and seedy, soft. Denies any diarrhea and constipation.
Eli sleeps on his back in the bassinet. He wakes at night to feed.
Eli makes appropriate noises for his age. Cries, but is easily consoled.
Gross Motor: Child is able to lift head, exhibit equal movements on extremities and kick
vigorously.
Language: Child is able to vocalize and "ooo/aah".
Fine Motor: Child is able to follow to midline.
Personal-Social: Patient does regard face, smile responsively, quiets to voice.
ROS:
General: Mother states no fever, Denies chills, fatigue, night sweats no weight loss,
no decrease in appetite
Skin: Mother denies any rash, no changes in hair or nails.
Head: Mother denies any lumps or lesions, no pain.
Ears: Mother denies any pulling at the ears, denies discharge.
Eyes: Mother denies any infections or drainage, no change in vision, no tearing,
denies pain.
Nose: Mother states no drainage, no bleeding or sinus infections.
Mouth and Throat: Mother denies any hoarseness, no bleeding or lesions.
Neck: Mother denies any lumps or lesions, no trauma, no pain or stiffness.
Cardiovascular: Mother denies any history of murmurs or heart troubles.
Respiratory: Mother denies cough, denies SOB, no history of asthma.
Objective:
Vital Signs: 19.25’’. 6 lb 2 oz (increased from 5lb 3oz on 1/ 17), head circ- 35.5
cm, T- 98.7 R
General: well nourished and alert. Weighs within the normal range. Mucous
membranes are moist and pink. Capillary refill is brisk/less than 2 seconds.
Respiratory pattern is unremarkable. No grunting or nasal flaring.
Head/Face: Head size: normocephalic, symmetric. Palpation reveals smooth,
symmetric skull. Anterior fontanelle is slightly concave and soft. Posterior fontanelle
is present.
Eyes: EOMI. PERRL and no iris abnormalities. Red reflex intact bilaterally. Normal
eye movement.
ENMT: External ears: ears normally positioned and aligned and ears normal in size.
Auditory canals are patent. Tympanic membranes normal landmarks, no fluid or
erythema bilaterally. Nares are patent. Nasal mucosa shows moistness and normal
color, but no discharge. Palate normal in appearance. Oral mucosa: pink, smooth and
moist. Sucking reflex is present.
Neck: Supple. No masses.
Resp: Lungs are clear bilaterally.
CV: PMI is not displaced. Rhythm is regular. No heart murmur appreciated.
GI: Abdomen is soft, nondistended and nontender. Cord stump is not present. (mom
states he lost it around the 20th) Bowel sounds normoactive. No abdominal masses.
No palpable hepatosplenomegaly.
Anus/Perineum: Anus and perineum appear normal.
Musculo: Spine: Spinal contour is normal. Even gluteal fold. Upper Extremities:
Normal to inspection and palpation. Shoulders: Smooth, regular clavicles bilaterally.
Hips: Stable, without clicking.
Skin: No rash, lesions or petechiae. No discoloration.
Neuro: Babinski reflex is present bilaterally. Moro's reflex is present
A: Healthy Male 24 day old infant – ICD 9 Code: V20.2
P: Start vitamin D drops supplement daily, Continue to breast feed, start pumping if
Mom wants to.
Anticipatory Guidance:
Discussed parental concerns regarding nutrition and feeding, avoiding honey and no
need for solids.
Discussed no bottle propping, colic, cool mist humidifier use, immunizations, lead
sources, passive smoke, spitting up and temperature/fever.
Discussed verbal stimulation and visual stimulation.
Discussed bed and nap routine, night awakening and use of pacifier.
Discussed animals, car seat in back facing rear, burns, choking, smoke detectors,
injury prevention, second hand smoke, skin protection, crib safety, sleeping on back,
tub safety, not leaving baby unattended on high surfaces and water safety.
F/U: Follow up at 2 month exam when Eli will get immunizations, call the office with
any questions or concerns