NEWBORN SOAP NOTE | NEWBORN SOAP NOTE Rated A+

NEWBORN SOAP NOTE Rated A+ NEWBORN SOAP NOTE Identifying Data: • Date of Visit: September 9, 2020 • Patient Name: R.F. • Age: 6 Weeks • Sex: Male • Ethnicity: Hispanic • Date of Birth: 7/28/2020 • 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 20.3 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 7/29/2020 • Surgery: None • Hospitalizations/Injuries/Accidents/Trauma/Illnesses: None • Nutrition Uptake: Reduced breast feeding, and formula over past 2 days Family History: • Mother: Denies any illnesses, or diseases • Father: No Known Issues Social History: • RF is the only child and lives at home with parents, and paternal grandmother. The mother states that the father has been deployed on 2nd tour in Afghanistan, US Marines, was absent for birth of RF and will not be back until November 2020. Mather denies the use of any drugs, denies smoking, drinking, but does state she consumes 1-3 cups of coffee a day for staying awake for work and to care for RF. Review of Systems (ROS): • General: Mother states fever as in HPI. Mother denies newborn has SOB, or difficulty breathing. She states reduced appetite and episodes of lethargy in newborn in past 2 days. • Neurological. Mother denies any seizures for newborn, denies neck stiffness, or abnormal facial features of newborn. • HEENT: ▪ Head: Denies any trauma or abnormalities to newborn’s head. ▪ Ears: Denies any discharge from newborn’s ears or tugging. ▪ Eyes: Denies newborn with conjunctivitis, discharge, or redness ▪ Nose: Denies nasal discharge, redness, or abnormalities ▪ Throat: Denies newborn swallowing issues, spitting up during feedings, breast or formula milk, denies gagging, or vomiting ▪ Neck: Denies any stiffness of newborn’s neck, states no issue moving head, no crying when doing so • Respiratory: Mother denies newborn with any difficulty breathing, wheezing, congestion, or cough. • Cardiovascular: Denies chest pains, SOB on exertion, bluish or grayish color around eyes, skin, lips, or nails. • Gastrointestinal: Mother denies newborn with having diarrhea, vomiting, but does state changes in appetite and fluid intake. Mother denies any abnormalities of waste in diapers, no blood. • Gastro Urinary: Mother denies newborn with changes in wetting, redness or abnormal genitalia, rashes, discoloration, redness, or swelling • Musculoskeletal: Mother states newborn moves extremities equally well, randomly and with no distress. Mother denies any trauma or injury to newborn. • Skin: Mother denies any discoloration, redness, dryness, or weight loss • Endo/Heme: Mother denies any swelling, ambiguous genitalia or growth abnormalities, denies easily bruising, or bleeding of newborn. OBJECTIVE DATA: • Vital Signs: Rectal Temp.101.5F, P 135, RR 30, O2 Sat 98% room air, Head Circumference 39.5 cm (50%), Height: 56.2 cm (22.1 in), Weight: 5.21 kg (11 lbs.) • Physical Examination: ▪ General: RF is awake in mother’s arms, eyes open, random body movements, no crying present. ▪ HEENT: ▪ Head: Normocephalic, atraumatic, with no meningeal signs, and with a soft anterior frontanelle. No lesions, scaling, flakes, or masses noted. No masses noted. Hair is clean and combed, evenly distributed, dark black hair. ▪ Eyes: No conjunctivitis, discharge, or icterus. ▪ Ears: No discharge, Rt, and Lt, tympanic membranes without erythema, good light reflex. ▪ Nose: Moist, pink nasal mucosa without nasal discharge. ▪ Throat: Moist, pink mucous membranes, gums are pink. No lesions noted to oral mucosa or tongue. ▪ Neck: Supple, tend, anterior cervical lymph nodes palpable. ▪ Respiratory: No SOB, respiration even, unlabored, clear auscultation. No pallor, cyanosis, or wheezing noted, equal chest expansion ▪ Cardiovascular: S1, S2 noted, RRR. No murmurs, palpitations noted. ▪ GI: Soft and non-tender, bowel sounds present all 4 quadrants. No distension or masses felt upon palpation. ▪ Musculoskeletal: FOM all extremities ▪ Skin: Soft, warm, dry intact without lesions, or rashes. ▪ Neurological: Moro reflex intact and symmetric ASSESSMENT: • Diagnosis: Disturbance of temperature regulation of newborn, unspecified ICD-10-CM code P981.9 ▪ The 6-wk. old newborn has a disturbance in body temp. regulation with a fever at 101.5F, other symptoms are feeding pattern, and episodic moments of irritability, and fatigue. The newborn has not been previously ill, nor did they have any respiratory issues, and from PMHx the newborn was a healthy baby, without complications from day of birth, and only vaccine was more than 24 hors ago, the (HepB) vaccine can cause side effects which are similar to RF’s. Recombivax [hepatitis b vaccine (recombinant)] is a viral vaccine used to help prevent the disease Hepatitis B. Common side effects of Recombivax include, irritability, fever, headaches, tiredness, sore throat, runny or stuffy nose, nausea, loss of appetite, weakness, and diarrhea. • Differential Diagnoses: Gastroenteritis (K52.9)- The symptoms of gastroenteritis are fever, poor appetite, irritability, all of which newborn. Enterovirus infection, unspecified (B34.1)- RF has the symptoms of fever, and irritability which could be diagnosed as a enterovirus, but except that he did not display other symptoms such as URI, or on PE wheezing, coughing, rash, abdominal pain, it was R/O. A mild upper respiratory infection (URI) is common and may include complaints of sore throat, fever, vomiting, diarrhea, anorexia, coryza, abdominal pain, rash, and headache. Neonatal urinary tract infection (P39.3)- In the subjective and objective data RF never had a UTI, but he did have similar symptoms which could have pointed to this differential diagnosis, as he displayed irritability, fever, poor feeding, but did not have strong smelling urine noted in his diapers, nor any vomiting or abdominal pain. Plan: • CPT code 85025: CBC CPT code 80053: Comprehensive metabolic panel (CMP) CPT code 4420: C-reactive protein (CRP) CPT code 51701: Straight catheter urinalysis, CPT code : Nasal swab and wash for Flu and for Respiratory Syncytial Virus. Treatment Plan • The mother is advised to call the office daily at 2pm to report temperature measurement during this period. • She is advised to call next day for RF’s lab results. • The mother is advised to try and breastfeed RF more often, even if his nursing time is less. A 2-3 hour feeding every day. • The mother is provided with Tylenol (acetaminophen 10mg/kg/dose) as directed every 6 hours as needed for fever. • The mother is asked to track the number of wet diapers every day and call office daily at 2pm to report total during this period. Education: ▪ Educated mother on importance that for now she try to breast feed more the newborn as breast milk is not only better for his immune system, but also can help to reduce his fever, ▪ The mother is also made aware to look for clues such as cough, congestion, rash, persistent or worsening changes in feeding patterns, crying and/or irritability related to fever etiology; and to closely monitor patient continuously as we await lab results. ▪ Reduce bottle feeding for present time as it may also lead to other issues for newborn, such as over-eating, and childhood obesity down the road,