Infant Well Visit Zachary LaFontaine Shadow health Transcript

Interviewer: Hi, I am Anthony. I will interview and examine you.

Date and Time: 05/28/22 1:43 AM EDT

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Greeting:
Anthony: Hi.
Anthony: What is your relationship with the patient?

Question:
Interviewee: Yes, Zachary is my son.
Anthony: Why are you here today?

Question:
Interviewee: We’re here for Zachary’s wellness visit. It was hard to work it into our schedule, but I know it’s important.
Anthony: Do you breastfeed your son?

Question:
Interviewee: 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.
Anthony: Do you give him both breasts?

Question:
Interviewee: I feed Zachary about 10 minutes on each side. So that’s 20 minutes.
Anthony: Do you supplement with formula?

Question:
Interviewee: Zachary only gets breastmilk, no formula at all.
Interviewee: This is one area where Zachary and I do great. Feeding is never painful and he latches well.
Anthony: Do you prefer breastfeeding to formula?

Question:
Interviewee: 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.
Anthony: How do you feel about your family life?

Question:
Interviewee: 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.
Anthony: Do you have enough time to breastfeed?

Question:
Interviewee: 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.

Empathizing:
Anthony: I’m sorry about that.
Interviewee: That’s nice of you.

Question:
Anthony: What is your son’s feeding schedule?

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Question:
Interviewee: I try for 2-3 hours during the day and 3-4 at night. We don’t always manage it, though.
Anthony: Do you feed your son the same time every day?

Question:
Interviewee: Zachary’s feeding schedule depends on what classes I have that day. So feedings change with the days of the week.
Anthony: What is your son’s sleep schedule?

Question:
Interviewee: 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.

Educating:
Anthony: You should ensure that your son sticks to sleep schedule.
Interviewee: Good to know.

Question:
Anthony: Do you sleep with your son?

Question:
Interviewee: 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.

Question:
Anthony: How many times does your son urinate?

Question:
Interviewee: He has about 5 or 6 wet diapers a day.
Anthony: How many times does he defecate per day?

Question:
Interviewee: Usually three times a day, sometimes less than that.
Anthony: What is the consistency of your son’s feces?

Question:
Interviewee: They’re soft.
Anthony: Does your son smile?

Question:
Interviewee: Zachary is a very happy baby. He smiles quite a bit. It’s nice coming home from school or work to see him.
Anthony: Does he track objects with eyes?

Question:
Interviewee: He does, yes. He also loves staring at strangers. He seems curious about everything.

Empathizing:
Anthony: I’m sorry about that.
Interviewee: Thanks.

Exam Actions:

– Inspected head circumference growth chart.
– Inspected weight and length growth chart.
– Inspected nose.
– Inspected ears.
– Frenulum attached in the middle of the mouth floor. Appropriate length and movements. Appears thin. Palate meets at the midline completely. Tongue appears smooth, and uvula located at midline.
– Inspected skin.
– Inspected skin: diaper area.
– Inspected genitalia.
– Assessed Musculoskeletal Barlow and Ortolani.
– Assessed eyes: pupils.
– Assessed Eye Tracking.
– Assessed extremities.
– Assessed grasp: Able to lift shoulders off the table with expected head lag.
– Assessed Moro Reflex: Infant briskly abducts arms and legs symmetrically, then brings legs up against the trunk.
– Assessed Tonic Reflex and neck range of motion.
– Assessed pulse.
– Assessed Rooting Reflex: Infant turns head in the direction of stimulus and opens mouth.
– Infant response with a sucking motion. Tongue protrudes past lips.
– Assessed neurological stepping/walking reflex.
– Palpated abdomen.
– 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.
– Auscultated Upper Right Abdomen: Abdomen rounded, appropriate for age.

Zachary LaFontaine Infant Well Visit Shadow health Objective Data Collection

– Auscultated Upper Left Abdomen: Abdomen rounded, appropriate for age.
– Auscultated Lower Right Abdomen: Abdomen rounded, appropriate for age.
– Auscultated Lower Left Abdomen: Abdomen rounded, appropriate for age.
– Auscultated Top Right Chest: Apical pulse palpated reveals rate steady and regular intervals.
– Auscultated Top Left Chest: Apical pulse palpated reveals rate steady and regular intervals.
– Auscultated Lower Left Chest: Apical pulse palpated reveals rate steady and regular intervals.
– Auscultated Upper Left Chest: Apical pulse palpated reveals rate steady and regular intervals.
– Auscultated Lower Left Chest: Apical pulse palpated reveals rate steady and regular intervals.
– Auscultated Upper Upper Right Chest.
– Auscultated Upper Upper Left Chest.
– Auscultated Upper Right Chest.
– Auscultated Upper Left Chest.
– Auscultated Lower Right Chest.
– Auscultated Lower Left Chest.
– Auscultated Upper Upper Left Back.
– Auscultated Upper Upper Right Back.
– Auscultated Upper Left Back.
– Auscultated Upper Right Back.
– Auscultated Lower Left Back.
– Auscultated Lower Right Back.