Infant Well Visit Zachary LaFontaine Shadow health Transcript
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Hi, I am Anthony, I will interview and examine you
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Greet |
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Hi.
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what is your relationship with the patient?
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Yes, Zachary is my son.
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Why are you here today?
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We’re here for Zachary’s wellness visit. It was hard to work it into our schedule, but I know it’s important.
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Do you breastfeed your son? Infant Well Visit Zachary LaFontaine Shadow health Transcript
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I breastfeed Zachary. It’s important to me that I do. It’s been challenging–my mother helps me out with a lot of advice, but she never breastfed so it’s new for both of us.
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Do you give him both breasts?
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I feed Zachary about 10 minutes on each side. So that’s 20 minutes.
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Do you supplement with formula?
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Zachary only gets breastmilk, no formula at all.
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This is one area where Zachary and I do great. Feeding is never painful and he latches well.
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Do you prefer breastfeeding to formula?
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I want to only breastfeed Zachary. I know formula is an option, but that would be a last resort. I want to focus on giving my baby breast milk.
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How do you feel about your family life?
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I’m glad I live at home. It helps to be with my mom and dad. I do my best to take care of myself, but my focus is Zachary.
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Do you have enough time to breastfeed? Infant Well Visit Zachary LaFontaine Shadow health Transcript
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I just don’t have enough time to breastfeed. I want to, but I work and go to school. I’m so busy, and it’s just overwhelming to fit everything in, plus breastfeeding.
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Am sorry about that
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Empathize |
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That’s nice of you.
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What is your son’s feeding schedule?
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I try for 2-3 hours during the day and 3-4 at night. We don’t always manage it, though.
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Do you feed your son the same time every day?
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Zachary’s feeding schedule depends on what classes I have that day. So feedings change with the days of the week.
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What is your son’s sleep schedule?
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That’s a complicated answer. Zachary sleeps 16 hours a day on Monday, Wednesday, Friday and the weekends. I’m not sure about Tuesday or Thursday, I have class those days. I know my mom gives him an extra nap.
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You should ensure that your son sticks to sleep schedule
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Good to know.
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Do you sleep with your son?
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Zachary sleeps in a bassinet at night or sometimes in his cradleboard. He’s always swaddled and always on his back. I keep the bassinet empty and in my room, so I’m always nearby. I’m really afraid of SIDS or anything like that, so I did a lot of reading on sleep safety.
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How many times does your son urinate?
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He has about 5 or 6 wet diapers a day.
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How many times does he defecate per day?
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Usually three times a day, sometimes less than that.
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What is the consistency of your son’s feces:?
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They’re soft.
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Does your son smile?
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Zachary is a very happy baby. He smiles quite a bit. It’s nice coming home from school or work to see him.
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Does he track objects with eyes?
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He does, yes. He also loves staring at strangers. He seems curious about everything.
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| Infant Well Visit Zachary LaFontaine Shadow health Transcript | ||
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Am sorry about that
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Empathize |
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Thanks
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Inspected head circumference growth chart
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Inspected weight and length growth chart
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Inspected nose
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Inspected ears
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Frenulum attached middle of mouth floor. Appropriate length and movements. Appears thin. Palate meets at the midline completely. Tongue appears smooth and uvula located at midline.
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Inspected skin
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Inspected skin: diaper area
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Inspected genitalia Infant Well Visit Zachary LaFontaine Shadow health Transcript
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Assessed Musculoskeletal Barlow and Ortolani
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Assessed eyes: pupils
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Assessed Eye Tracking
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Assessed extremities
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Assessed grasp: Able to lift shoulders off table with expected head lag.
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Assessed Moro Reflex: Infant briskly abducts arms and legs symmetrically, then brings legs up against trunk.
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Assessed Tonic Reflex and neck range of motion.
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Assessed pulse
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Assessed Rooting Reflex: Infant turns head in direction of stimulus and opens mouth. Infant Well Visit Zachary LaFontaine Shadow health Transcript
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Infant response with sucking motion. Tongue protrudes past lips.
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Assessed neurological stepping/walking reflex
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Palpated abdomen
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Anterior fontanelle palpated 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.
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Auscultated Upper Right Abdomen: Abdomen rounded, appropriate for age.
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Auscultated Upper Left Abdomen: Abdomen rounded, appropriate for age.
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Auscultated Lower Right Abdomen: Abdomen rounded, appropriate for age.
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Auscultated Lower Left Abdomen: Abdomen rounded, appropriate for age.
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Auscultated Top Right Chest: Apical pulse palpated reveals rate steady and regular intervals.
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Auscultated Top Left Chest: Apical pulse palpated reveals rate steady and regular intervals.
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Auscultated Lower Left Chest: Apical pulse palpated reveals rate steady and regular intervals.
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Auscultated Upper Left Chest: Apical pulse palpated reveals rate steady and regular intervals.
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Auscultated Lower Left Chest: Apical pulse palpated reveals rate steady and regular intervals.
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Auscultated Upper Upper Right Chest
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Auscultated Upper Upper Left Chest
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Auscultated Upper Right Chest
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Auscultated Upper Left Chest
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Auscultated Lower Right Chest
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Auscultated Lower Left Chest
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Auscultated Upper Upper Left Back
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Auscultated Upper Upper Right Back
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Auscultated Upper Left Back
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Auscultated Upper Right Back
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Auscultated Lower Left Back
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Auscultated Lower Right Back Infant Well Visit Zachary LaFontaine Shadow health Transcript
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