NUR 600 SOAP Note 2-Month-Old Male Infant Well
Child Exam Latest Update 2025
S: Subjective
Identifying Data and Reliability:
Mother (Ms. L) presents with her 2-month-old son, ZF, for a routine wellness visit and
serves as the reliable historian.
Chief Complaint:
Mother states, “It was hard to work it into our schedule, but I know it’s important.”
History of Present Illness:
ZF is a 2-month-old male born at 39 weeks via vaginal delivery with no birth
complications. Birth weight was 7 lbs 4 oz and length was 19 inches. APGAR scores
were 9 at 1 minute and 10 at 5 minutes. He is exclusively breastfed 2–3 hours during
the day and every 3–4 hours at night, feeding for approximately 10 minutes per breast
(20 minutes total). Mother reports that her breasts feel full before feeds but do not
always feel empty after. She does not have a breast pump due to cost and struggles
with consistent feeding times due to her busy school and work schedule. ZF typically
has 5–6 wet diapers and 3 bowel movements per day that are soft and mustard-
colored.
Sleep is about 16 hours/day on M-W-F; uncertain on T/Th when mother is at school.
Infant is not in daycare but is cared for by grandmother when mother is away. Sleeps in
a bassinet in mother's room, always on back. No smoke exposure reported.
Nutrition: Exclusively breastfed. No formula.
Elimination: 5–6 wet diapers/day, 3 mustard-colored soft BMs/day.
Sleep: 16 hours/day on M-W-F. Trouble sleeping on T/Th.
Development: Coos, smiles, tracks objects, responds to sounds, lifts head during
tummy time.
Safety: Car seat rear-facing in back seat. Sleeps in bassinet in mother’s room, on back.
No bed-sharing.
Maternal Health: Reports feeling overwhelmed and tired. Limited support system. Eats a
healthy diet and drinks fluids. Denies breast pain or leaking.
PMH/Medications/Allergies:
No medications. No known drug allergies.
Immunizations:
Child Exam Latest Update 2025
S: Subjective
Identifying Data and Reliability:
Mother (Ms. L) presents with her 2-month-old son, ZF, for a routine wellness visit and
serves as the reliable historian.
Chief Complaint:
Mother states, “It was hard to work it into our schedule, but I know it’s important.”
History of Present Illness:
ZF is a 2-month-old male born at 39 weeks via vaginal delivery with no birth
complications. Birth weight was 7 lbs 4 oz and length was 19 inches. APGAR scores
were 9 at 1 minute and 10 at 5 minutes. He is exclusively breastfed 2–3 hours during
the day and every 3–4 hours at night, feeding for approximately 10 minutes per breast
(20 minutes total). Mother reports that her breasts feel full before feeds but do not
always feel empty after. She does not have a breast pump due to cost and struggles
with consistent feeding times due to her busy school and work schedule. ZF typically
has 5–6 wet diapers and 3 bowel movements per day that are soft and mustard-
colored.
Sleep is about 16 hours/day on M-W-F; uncertain on T/Th when mother is at school.
Infant is not in daycare but is cared for by grandmother when mother is away. Sleeps in
a bassinet in mother's room, always on back. No smoke exposure reported.
Nutrition: Exclusively breastfed. No formula.
Elimination: 5–6 wet diapers/day, 3 mustard-colored soft BMs/day.
Sleep: 16 hours/day on M-W-F. Trouble sleeping on T/Th.
Development: Coos, smiles, tracks objects, responds to sounds, lifts head during
tummy time.
Safety: Car seat rear-facing in back seat. Sleeps in bassinet in mother’s room, on back.
No bed-sharing.
Maternal Health: Reports feeling overwhelmed and tired. Limited support system. Eats a
healthy diet and drinks fluids. Denies breast pain or leaking.
PMH/Medications/Allergies:
No medications. No known drug allergies.
Immunizations:
