NURSING 340 L NEWBORN SOAP NOTE | SUBJECTIVE DATA: RF is a 6-week-old newborn male patient presents in mother’s arms...

NURSING 340 L NEWBORN SOAP NOTE Dr. Gitana Ng MD Identifying Data: • Date of Visit: September 9, 2019 • Patient Name: R.F. • Age: 6 Weeks • Sex: Male • Ethnicity: Hispanic • Date of Birth: 7/28/2019 • Visit Type: New Patient SUBJECTIVE DATA: RF is a 6-week-old newborn male patient presents in mother’s arms, who’s mother states he has been running a fever for 2 days and seems to have reduced time breastfeeding, and reduced amount of baby formula consumed. Chief Complaint (CC): • The Mother states “My baby has had a fever for 2 days and I’m very worried.” History of Present Illness (HPI): • The mother states that she noticed RF was warmer to the touch, so she took an axillary temperature of the baby which was 100.8F two days ago, and yesterday RF’s temperature was 101.9F. She noticed also that his appetite had reduced as he would not feed as much from her breast, refused to latch on, and when given baby formula RF would not consume more than 1 oz. The mother reports that RF has been more fussy than usual and wakes up crying more times than usual in these last two days. This morning the mother states that RF was lethargic and did not breast feed but did prefer small amount of formula less than 2oz. Past Medical History (PMH): • Mother states that RF was born through uncomplicated, spontaneous vaginal delivery full term 40 weeks, he is her first child. Mother dienes diabetes, HTN, or any conditions which complicated the pregnancy. The mother states that RF’s birth wt. was 7.5lbs. (3.4 kg), and 19.3 inches (49 cm) long. The mother states that she had an Epidural block for pain during labor, and Ibuprofen after delivery for pain. She states that she and RF hospitalization stay was only two days and discharged with no issues. Mother denies smoking, or anyone in household or neighbors use of tobacco. • Allergies: NKA • Current medications: None • Childhood illnesses: None • Immunization: Hepatitis B vaccine (HepB), given on 7/29/2019 • Surgery: None • Hospitalizations/Injuries/Accidents/Trauma/Illnesses: None • Nutrition Uptake: Reduced breast feeding, and formula over past 2 days Family History: . . . . . . Continued