SOAP Note – Newborn Wellness

SOAP Note – Newborn Wellness

ID: CC, DOB 1/6/2024 Age 12 weeks Gender: Female Race:  Hispanic.

She was brought to the clinic by her parents. The mother provided clinical information on the infant and is a reliable historian.

Subjective:

CC: “I have come for the monthly check-up on the child.”

HPI: CC is a nine-week-old infant brought to the clinic by her mother for a routine wellness check. Her last wellness check was one month ago and was negative for any developmental or infant health anomalies. CC was born through spontaneous vaginal delivery. She was born with a birth weight of 5.9 lbs. The mother reported that the child has been doing well since her last wellness check. She is exclusively breastfeeding and has not had any health shocks over the past weeks. The mother reported that CC has no sleep problems, feeding concerns, fever, or unusual crying.

Past Medical History:

• Medical problem list

CC was started on prophylactic ampicillin and gentamycin immediately after delivery to lower her risk for infections, as her mother developed a fever just before giving birth to her. According to Shifera et al. (2023), a maternal fever of more than 38 degrees is a risk factor for child infections, warranting prophylactic antibiotics on neonates.

• Surgical:

–  CC has no history of surgeries.

Preventive Care:

-CC has been presenting for her routine wellness checks. Her first postnatal clinical visitations were on the third day after birth, with subsequent visits on the 14th day and the first month after birth.

Allergies:

– No known allergies.

Medications:

-The child is not on any medications.

Immunizations:

– The child received her first dose of the HepB vaccine at birth.

Birth History

– The child was born through spontaneous vaginal delivery after 39 weeks gestation and without any birth complications. The maternal pulse rate was 100 beats per minute at birth. The maternal temperature was initially 38.7 degrees pre-labor but subsided to 37.7 upon intravenous paracetamol administration. The APGAR score of the newborn was 8/10. A repeat APGAR score after five minutes was 9/10. The length of the baby at birth was 19 inches, with a head circumference of 13.7 inches. The mother was discharged from the clinic after five days of confinement. The sustained confinement was to ensure both the mother and the child were free from infections.

Social History:

• Chemical history: The mother has a history of alcohol use and smoking. She reported occasionally drinking “a few bottles” during her pregnancy. She also reported smoking at least once when she was pregnant. She, however, denies ever having smoked or drank alcohol since giving birth to the child.

Other:

CC is the last born in a family of six. She has five other siblings with the oldest being 13. the family lives in a two-bedroom unit in a low-income neighborhood. She sleeps with her two parents and brother, aged 3 years, in the same space. The family eats three meals a day but struggles to achieve a balanced diet as they are unable to constantly afford fresh vegetables and fruits. The child breastfeeds every two to four hours. She sleeps for over 15 hours, with approximately 5 hours of daytime sleep. The daytime periods of sleep are often in the form of naps lasting between 45 minutes to 2 hours. Denies any exposure to violence or smoking.

• Safety:

The family does not own any guns or cars. The mother came to the clinic in a public transport vehicle holding the child in her arms.

• Family History:

The family has no history of physical or psychiatric health illnesses.

• Developmental Milestones

The newborn smiles at people, recognizes faces and is responsive to sounds. She is also able to open and close her hands, make goo sounds, hold her head up momentarily whenever she is lying on her tummy, open and close her hands, and move both her arms and legs. The child can also look at the parents and follow their movements.

Review of Systems

All the ROS findings were obtained from the mother.

Constitutional: The mother noted that the child is well, with no signs of chills, fever, or chills.

Eyes: Denies eye discharge, swelling, or puffiness. The mother also denies seeing the child rubbing her eyes constantly.

Ears: Denies ear discharge, swelling around the ears, or signs of rubbing of the ears.

Nose: Denies nasal congestion or discharge.

Neck/Throat: Denies lesions, swelling, or masses on the child’s neck.

Cardiovascular: Denies palpitations, irregular heart rates, tachycardia, or bluish discolorations of the lips and extremities.

Pulmonary: Denies labored breathing, tachypnea, episodes of apnea, or coughs.

Gastrointestinal: Denies diarrhea, vomiting, constipation, feeding difficulties, distension, or colicky pain.

Genitourinary: Denies any voiding inconsistencies, unusual coloration of the infant’s urine, or foul-smelling urine.

Musculoskeletal: Denies muscle pain, muscle stiffness, or pain at the joints.

Integumentary: Denies skin lesions, swellings, rashes, scars, or skin color inconsistencies.

Neurological: Denies seizures or lethargy.

Endocrine: Denies cold or heat intolerance, sensory deficits, recent weight loss, or weight gain.

Hematologic/Lymphatic: Denies bruising, lymph swelling, or unusual bleeding.

Allergic/Immunologic: The patient has no known allergies.

Objective

Vital Signs: HR: 144 Temp: 36.8 RR: 36 SpO2: 98% Height/Length: 53.34 cm. BMI: 18.1

Weight: 11lbs 2oz.  Head Circumference: 13’7 inches.

Labs, radiology, or other pertinent studies: N/A

Physical Exam

General Survey: The child is alert and appears age-appropriate. She has a normal flexed posture and is responsive to the examination. She is active, well nourished, and does not appear to be in distress.

HEENT: The head is well-rounded and normocephalic. No sign of bruising, lesions, swelling, masses, or trauma. The posterior fontanelle is closed. The eyes are symmetrical. The pupils are round and reactive to light. No signs of eyelid edema, discharge, or erythema. The ears are symmetrical. No signs of ear swelling. The tympanic membrane is intact and grayish in coloration. The nose is symmetrical and well-positioned on the face. No sign of blockage or narrowing in the nasal passages. The palate is intact. No sign of cysts in the gingiva. The tongue is extended beyond the lower gum and can move freely on the buccal cavity without any restrictions. The uvula is midline. The tonsils, on the other hand, are intact with no sign of tonsilar swelling or inflammation.

Neck: The neck is symmetrical. No signs of masses, head tilt, goiter, or webbing in the neck. There are also no signs of thyroglossal duct cysts or any other lesions on the neck.

CVS: The heart rate is regular and rhythmic. S1 and S2 sounds were heard on auscultation. No murmur sounds were heard. Equal peripheral sounds were also heard bilaterally. The extremities are warm to the touch. No sign of pallor, cyanosis, or bluish coloration. The capillary refill time on the upper and lower extremities is 2 seconds

Chest/Thorax/Clavicles: The chest wall is symmetrical. No signs of pectus excavatum or pectus carnatum. The rise and fall of the chest wall is symmetrical, with no signs of difficulty in breathing or use of accessory muscles of inspiration. Clear lung sounds on auscultation, with no wheezing or crackling sounds heard. The clavicles are symmetrical on palpation, with no signs of swelling or crepitus.

Abdominal: The abdomen is well-rounded and symmetrical. There are no signs of abdominal distension, hernia, lesions, masses, scars, or skin color inconsistencies. Bowel sounds are present on auscultation. The abdomen is soft on palpation, with no signs of organomegaly, tenderness, or masses.

Genitourinary: The folds of the labia majora and minora are intact. The vaginal opening is also visible, with no signs of hernias, swelling, or vaginal lesions.

Integumentary: The skin was soft, warm, normal turgor, and moist. No signs of scars, skin swellings, lesions, rashes, or skin color inconsistencies.

Musculoskeletal: No signs of joint swelling, or restricted range of motion in all joints. there are also no signs of joint malformations. The arms and the legs are symmetrical bilaterally. No sign of congenital hip hyperplasia. The Barlow and Ortolani maneuver tests were negative.

Back/ Sacral: The back is symmetrical. No signs of lesions, scars, swelling, or masses on the back. The pine is symmetrical and palpable throughout its length. No sign of a sacral dimple.

Neurological Examination

The sucking, grasp, Moro, rooting, and stepping reflexes were intact.

Assessment

Differential Diagnoses

1. Encounter for routine child health examination without abnormal findings (ICD 10 Z00.129): Encounter with routine child examination without abnormal findings denotes the absence of factors influencing the health and wellness of children. Clinical wellness checkups are integral to healthy living and thriving for neonates (WHO, 2024). Regular health examination allows caregivers to identify factors within the child’s environment and health parameters that may influence their contact with clinical services. These may include immunizations, exposure to environmental toxins, and access to high-quality healthcare services, among others. Healthy People 2030 focus on keeping newborns healthy and safe through their first year. It advocates for breastfeeding through the first year of life, screening for hearing loss by the first month, childhood vaccination, and reduced risk for communicable diseases through infection prevention (Healthy People 2030, n.d.). The child in the case presented is nine weeks old. Assessment findings revealed several aspects that meet the CDC criteria for child wellness. These include exclusive breastfeeding, routine wellness checks, and vaccinations (Brody, 2019). Furthermore, the clinical presentation and collaborative history were negative for any significant health compromise. This warranted the inclusion of this differential.
2. Encounter for immunization (ICD-10-CM Diagnosis Code Z23): Childhood vaccinations remain integral to children and neonatal wellness. CDC notes that childhood vaccinations are the safest strategies for long-term health outcomes, reduced hospital visitations, death prevention, and guarantee for community health (CDC, 2024). Vaccines prevent children from infectious diseases such as measles thereby lowering potential morbidity and mortality accustomed to various infectious illnesses.  Likewise, vaccines reduce associated out-of-pocket costs attributable to vaccine-preventable diseases (Nandi & Shet, 2020). This warrants the use of vaccines in children. The CDC outlines a child and adolescent immunization schedule applicable to American children and adolescents. Some of the childhood vaccines fronted by the CDC include RSV vaccines, rotavirus vaccines, hepatitis B vaccines, and DPT vaccines among others.  The child in the case presented received the first dose of the Hep B virus vaccine. She is now eligible for the first dose of rotavirus, DTaP (Diptheria, Tetanus, and acellular pertussis), pneumococcal conjugate, and IPV vaccines (CDC, 2024). In the pursuit of child wellness, and per the CDC and the Healthy People 2030 initiative on neonatal health and wellness, the child should receive the recommended vaccines.
3. Contact with a child with suspected exposure to communicable diseases (ICD-10 Code Z20.89): An encounter with a child suspected or at risk of being exposed to communicable diseases signifies the presence of modifiable factors within the child’s life that may predispose them to infectious diseases. Children are especially susceptible to infectious diseases. This can be attributed, in part, to their inadequately developed immune systems to fight infectious agents such as bacteria and viruses. Several factors play a role in the development of infections in neonates. Household overcrowding is one of the identified contributory factors to neonatal infections.  It has been associated with an increased prevalence of gastroenteritis, diarrheal illnesses, and acute respiratory infections (Kamis et al., 2021). This makes it a concern in neonatal health preservation. The child in the case presented is the last born in a family of seven. Collaborative findings revealed that the house is overcrowded, as evidenced by her being forced to live in the same living space with her parents and two siblings. The presence of more than 1.5 persons in a single room constitutes overcrowding in the U.S. (Kamis et al., 2021). Having four people share a room, as in the case presented, constitutes overcrowding. The child is, therefore, at risk of developing various infectious diseases.

Diagnosis: Encounter for routine child health examination without abnormal findings (ICD 10 Z00.129): physical examination of the child, along with collaborative findings, revealed that the child is healthy. She met the immunization criteria set by the CDC as she has received all the scheduled vaccines so far and was actively breastfeeding. Furthermore, a physical exam noted that she was healthy for her age, with no sign of any structural abnormality (CDC, 2024). The healthcare-seeking behavior of the family was also optimal, as they have attended all their routine wellness checks so far. Notwithstanding, some of the environmental factors identified in the child’s case, such as maternal exposure to alcohol and household overcrowding, may present significant health concerns to the child. They are, however, not a current concern as the health indicators of the child, such as birth weight, physical appearance, and vitals are within the average range of a child at her age. Further assessment, including household visitation, to inspect the hygiene status and the living conditions of the family to help ascertain the child’s risk for communicable diseases.

Plan

Encounter for routine child health examination without abnormal findings (ICD 10 Z00.129):

Diagnostics:

• Weight, height, and head circumference measurements are the only screening checks mandated for a nine-week-old baby. Other tests may be included only when there is a reason to perform them. CBC evaluation is only warranted in the presence of clinical suspicion for sepsis (CDC, 2024). In the case presented, the child weighed 11 pounds, had a head circumference of 13’7 inches, and a height of 12 pounds. There were no abnormal findings during the assessment and physical examination that pointed toward the need for further diagnostics.

Treatment:

• Hepatitis B vaccine: The child will receive her second dose of the Hepatitis B vaccine. According to the CDC schedule on childhood vaccination, the second dose of the HepB vaccine should be administered by the second month. Thus, the child will receive her second dose of the vaccine (CDC, 2024).
• Rotavirus vaccine: The child is also eligible to receive RV1. The rotavirus vaccine provides immune protection against diarrheal illnesses attributed to rotavirus. She will be started on a two-dose rotavirus series with Rotarix. This vaccine is particularly beneficial to the child due to the presence of other environmental factors, such as overcrowding, that make her vulnerable to diarrheal illnesses (CDC, 2024).
• DTaP: The first dose of the Diphtheria, Tetanus, and acellular pertussis (DTaP) vaccine is usually administered as a five-dose series initiated in the second month of life. The vaccine provides immune protection against tetanus, diphtheria, and pertussis. The vaccine is important for the child as the living conditions of her household predispose her to infection from the Bordetella pertussis bacterium (CDC, 2024).
• Haemophilus influenza vaccine: The child is eligible for the PedvaxHIB vaccine, a three-series Haemophilus influenza type B vaccine initiated in the second month of life (CDC, 2024).
• Pneumococcal conjugate vaccine. The child will also receive the pneumococcal conjugate vaccine. This vaccine is administered as a four-dose series initiated in the second month of life. The child is at a high risk of respiratory infections due to her living conditions warranting this vaccine (CDC, 2024).

Education: 

• Social determinants of health: The child’s parents will be educated on the significance of their child’s health and wellness in her development, including the need for routine wellness checks on the health of their child. They will also be told of the impact of environmental factors within their current living space that may predispose the child to illnesses. In this respect, they will be educated on the health impacts of overcrowding and how they put their child at risk of developing respiratory and diarrheal illnesses (Kamis et al., 2021).
• Nutrition: The parents will be educated on the significance of proper infant nutrition in promoting the health of their child. In this respect, the mother will be advised to continue breastfeeding the child as breastfeeding is integral to the wellness and health of the child. She will also be advised to maintain optimum maternal nutrition to enhance the quality of breast milk (Mohamed Ahmed et al., 2023).
• Hygiene: The child’s parents should be educated on maintaining optimum hygiene. In this respect, they should be advised to wash their hands as needed, consume clean and well-washed foods, and drink clean water. They should also be told of the need to bathe the child one to time a week with clean water to protect her from infectious illnesses (Nalule et al., 2021).
• Child self-care: The mother will also be educated on the prerequisite skills for ensuring child wellness. This includes identifying when the baby is in distress and the appropriate measures to take. In this respect, she should be told to be on the lookout for unusual crying, high fever, unusual infant behavior, and whether the child meets the developmental milestones appropriate for her age. She should also be advised against leaving the baby alone (WHO, 2024).

Follow-Up:

• The child is expected to be presented to the clinic after one month. Monthly clinical visitations for newborns are recommended to allow for wellness checks. During these visitations, caregivers can assess whether the child is meeting her developmental milestones and can help identify any factors within the child’s life that may be impacting her wellness. However, she can seek care intervention whenever the child is in distress.

References

Brody, S. (2019). Newborn Health: Resources for New Mothers: A webliography. Journal of Consumer Health on the Internet, 23(3), 299–311. https://doi.org/10.1080/15398285.2019.1649948

CDC. (2024a, June 27). Child and adolescent immunization schedule by age (addendum updated June 27, 2024). Centers for Disease Control and Prevention. https://www.cdc.gov/vaccines/hcp/imz-schedules/child-adolescent-age.html

CDC. (2024b, August 14). Your child needs vaccines as they grow!. Centers for Disease Control and Prevention. https://www.cdc.gov/vaccines/imz-schedules/child-easyread.html

Healthy People 2030. (n.d.). Infants. Infants – Healthy People 2030. https://health.gov/healthypeople/objectives-and-data/browse-objectives/infants

Kamis, C., Stolte, A., West, J. S., Fishman, S. H., Brown, T., Brown, T., & Farmer, H. R. (2021). Overcrowding and covid-19 mortality across U.S. counties: Are disparities growing over time? SSM – Population Health, 15, 100845. https://doi.org/10.1016/j.ssmph.2021.100845

Mohamed Ahmed, S. O., Ashgar, R. I., Mohammed Abdelgader, A. A., Abdalla Hamid, H. I., Mathkor, D. M., Abdelsadig Ali, M. A., Mousa Mohmed, S. A., Ali Farg, S. J., Mohamed Ebrahim, R. A., Mustafa Gabir Tia, M., Humza Bashir, W. A., & Ali Hazazi, Z. H. (2023). Exclusive breastfeeding: Impact on infant health. Clinical Nutrition Open Science, 51, 44–51. https://doi.org/10.1016/j.nutos.2023.08.003

Nalule, Y., Buxton, H., Macintyre, A., Ir, P., Pors, P., Samol, C., Leang, S., & Dreibelbis, R. (2021). Hand hygiene during the early neonatal period: A mixed-methods observational study in healthcare facilities and households in rural Cambodia. International Journal of Environmental Research and Public Health, 18(9), 4416. https://doi.org/10.3390/ijerph18094416

Nandi, A., & Shet, A. (2020). Why vaccines matter: Understanding the broader health, economic, and Child Development Benefits of routine vaccination. Human Vaccines & Immunotherapeutics, 16(8), 1900–1904. https://doi.org/10.1080/21645515.2019.1708669

Shifera, N., Dejenie, F., Mesafint, G., & Yosef, T. (2023). Risk factors for neonatal sepsis among neonates in the neonatal intensive care unit at Hawassa University Comprehensive Specialized Hospital and Adare General Hospital in Hawassa City, Ethiopia. Frontiers in Pediatrics, 11. https://doi.org/10.3389/fped.2023.1092671

WHO. (2024, March 2). Improving the health and Well-being of Children and Adolescents: Guidance on scheduled child and adolescent well-care visits. World Health Organization. https://www.who.int/publications/i/item/9789240085336

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