Infant Well Visit Zachary LaFontaine Shadow health Transcript

Infant Well Visit Zachary LaFontaine Shadow health Transcript

Daanis LaFontaine.

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?

Shadow Health Tina Jones Mental Health Documentation

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.

Infant Well Visit Zachary LaFontaine Shadow health Transcript

Your Avatar.
Hi, I am Anthony, I will interview and examine you

Greet
05/28/22 1:43 AM EDT

Daanis LaFontaine.
Hi.
Your Avatar.
what is your relationship with the patient?

Question
05/28/22 1:43 AM EDT

Daanis LaFontaine.
Yes, Zachary is my son.
Your Avatar.
Why are you here today?

Question
05/28/22 1:44 AM EDT

Daanis LaFontaine.
We’re here for Zachary’s wellness visit. It was hard to work it into our schedule, but I know it’s important.
Your Avatar.
Do you breastfeed your son? Infant Well Visit Zachary LaFontaine Shadow health Transcript

Question
05/28/22 1:44 AM EDT

Daanis LaFontaine.
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.
Your Avatar.
Do you give him both breasts?

Question
05/28/22 1:45 AM EDT

Daanis LaFontaine.
I feed Zachary about 10 minutes on each side. So that’s 20 minutes.
Your Avatar.
Do you supplement with formula?

Question
05/28/22 1:46 AM EDT

Daanis LaFontaine.
Zachary only gets breastmilk, no formula at all.
Your Avatar.
Daanis LaFontaine.
This is one area where Zachary and I do great. Feeding is never painful and he latches well.
Your Avatar.
Do you prefer breastfeeding to formula?

Question
05/28/22 1:48 AM EDT

Daanis LaFontaine.
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.
Your Avatar.
How do you feel about your family life?

Question
05/28/22 1:49 AM EDT

Daanis LaFontaine.
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.
Your Avatar.
Do you have enough time to breastfeed? Infant Well Visit Zachary LaFontaine Shadow health Transcript

Question
05/28/22 1:50 AM EDT

Daanis LaFontaine.
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.
Your Avatar.
Am sorry about that

Empathize
05/28/22 1:50 AM EDT

Daanis LaFontaine.
That’s nice of you.
Your Avatar.
What is your son’s feeding schedule?

Question
05/28/22 1:51 AM EDT

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

Question
05/28/22 1:53 AM EDT

Daanis LaFontaine.
Zachary’s feeding schedule depends on what classes I have that day. So feedings change with the days of the week.
Your Avatar.
What is your son’s sleep schedule?

Question
05/28/22 1:54 AM EDT

Daanis LaFontaine.
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.
Your Avatar.
You should ensure that your son sticks to sleep schedule

Educate
05/28/22 1:55 AM EDT

Daanis LaFontaine.
Good to know.
Your Avatar.
Do you sleep with your son?

Question
05/28/22 1:56 AM EDT

Daanis LaFontaine.
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.
Your Avatar.
How many times does your son urinate?

Question
05/28/22 1:57 AM EDT

Daanis LaFontaine.
He has about 5 or 6 wet diapers a day.
Your Avatar.
How many times does he defecate per day?

Question
05/28/22 1:59 AM EDT

Daanis LaFontaine.
Usually three times a day, sometimes less than that.
Your Avatar.
What is the consistency of your son’s feces:?

Question
05/28/22 2:03 AM EDT

Daanis LaFontaine.
They’re soft.
Your Avatar.
Does your son smile?

Question
05/28/22 2:04 AM EDT

Daanis LaFontaine.
Zachary is a very happy baby. He smiles quite a bit. It’s nice coming home from school or work to see him.
Your Avatar.
Does he track objects with eyes?

Question
05/28/22 2:11 AM EDT

Daanis LaFontaine.
He does, yes. He also loves staring at strangers. He seems curious about everything.
Your Avatar.
Infant Well Visit Zachary LaFontaine Shadow health Transcript
Your Avatar.
Am sorry about that

Empathize
05/28/22 2:23 AM EDT

Daanis LaFontaine.
Thanks
Your Avatar.
 Inspected head circumference growth chart

Exam Action
05/28/22 2:24 AM EDT

Your Avatar.
 Inspected weight and length growth chart

Exam Action
05/28/22 2:24 AM EDT

Your Avatar.
 Inspected nose

Exam Action
05/28/22 2:26 AM EDT

Your Avatar.
 Inspected ears

Exam Action
05/28/22 2:26 AM EDT

Your Avatar.
 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.

Exam Action
05/28/22 2:26 AM EDT

Your Avatar.
 Inspected skin

Exam Action
05/28/22 2:27 AM EDT

Your Avatar.
 Inspected skin: diaper area

Exam Action
05/28/22 2:27 AM EDT

Your Avatar.
 Inspected genitalia Infant Well Visit Zachary LaFontaine Shadow health Transcript

Exam Action
05/28/22 2:27 AM EDT

Your Avatar.
 Assessed Musculoskeletal Barlow and Ortolani

Exam Action
05/28/22 2:27 AM EDT

Your Avatar.
 Assessed eyes: pupils

Exam Action
05/28/22 2:28 AM EDT

Your Avatar.
 Assessed Eye Tracking

Exam Action
05/28/22 2:30 AM EDT

Your Avatar.
 Assessed extremities

Exam Action
05/28/22 2:31 AM EDT

Your Avatar.
 Assessed grasp: Able to lift shoulders off table with expected head lag.

Exam Action
05/28/22 2:34 AM EDT

Your Avatar.
 Assessed Moro Reflex: Infant briskly abducts arms and legs symmetrically, then brings legs up against trunk.

Exam Action
05/28/22 2:34 AM EDT

Your Avatar.
 Assessed Tonic Reflex and neck range of motion.

Exam Action
05/28/22 2:34 AM EDT

Your Avatar.
 Assessed pulse

Exam Action
05/28/22 2:34 AM EDT

Your Avatar.
 Assessed Rooting Reflex: Infant turns head in direction of stimulus and opens mouth. Infant Well Visit Zachary LaFontaine Shadow health Transcript

Exam Action
05/28/22 2:35 AM EDT

Your Avatar.
 Infant response with sucking motion. Tongue protrudes past lips.

Exam Action
05/28/22 2:35 AM EDT

Your Avatar.
 Assessed neurological stepping/walking reflex

Exam Action
05/28/22 2:36 AM EDT

Your Avatar.
 Palpated abdomen

Exam Action
05/28/22 2:38 AM EDT

Your Avatar.
 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.

Exam Action
05/28/22 2:38 AM EDT

Your Avatar.
 Auscultated Upper Right Abdomen: Abdomen rounded, appropriate for age.

Exam Action
05/28/22 2:39 AM EDT

Your Avatar.
 Auscultated Upper Left Abdomen: Abdomen rounded, appropriate for age.

Exam Action
05/28/22 2:39 AM EDT

Your Avatar.
 Auscultated Lower Right Abdomen: Abdomen rounded, appropriate for age.

Exam Action
05/28/22 2:39 AM EDT

Your Avatar.
 Auscultated Lower Left Abdomen: Abdomen rounded, appropriate for age.

Exam Action
05/28/22 2:39 AM EDT

Your Avatar.
 Auscultated Top Right Chest: Apical pulse palpated reveals rate steady and regular intervals.

Exam Action
05/28/22 2:39 AM EDT

Your Avatar.
 Auscultated Top Left Chest: Apical pulse palpated reveals rate steady and regular intervals.

Exam Action
05/28/22 2:39 AM EDT

Your Avatar.
 Auscultated Lower Left Chest: Apical pulse palpated reveals rate steady and regular intervals.

Exam Action
05/28/22 2:40 AM EDT

Your Avatar.
 Auscultated Upper Left Chest: Apical pulse palpated reveals rate steady and regular intervals.

Exam Action
05/28/22 2:40 AM EDT

Your Avatar.
 Auscultated Lower Left Chest: Apical pulse palpated reveals rate steady and regular intervals.

Exam Action
05/28/22 2:40 AM EDT

Your Avatar.
 Auscultated Upper Upper Right Chest

Exam Action
05/28/22 2:40 AM EDT

Your Avatar.
 Auscultated Upper Upper Left Chest

Exam Action
05/28/22 2:40 AM EDT

Your Avatar.
 Auscultated Upper Right Chest

Exam Action
05/28/22 2:40 AM EDT

Your Avatar.
 Auscultated Upper Left Chest

Exam Action
05/28/22 2:40 AM EDT

Your Avatar.
 Auscultated Lower Right Chest

Exam Action
05/28/22 2:41 AM EDT

Your Avatar.
 Auscultated Lower Left Chest

Exam Action
05/28/22 2:41 AM EDT

Your Avatar.
 Auscultated Upper Upper Left Back

Exam Action
05/28/22 2:41 AM EDT

Your Avatar.
 Auscultated Upper Upper Right Back

Exam Action
05/28/22 2:41 AM EDT

Your Avatar.
 Auscultated Upper Left Back

Exam Action
05/28/22 2:41 AM EDT

Your Avatar.
 Auscultated Upper Right Back

Exam Action
05/28/22 2:41 AM EDT

Your Avatar.
 Auscultated Lower Left Back

Exam Action
05/28/22 2:41 AM EDT

Your Avatar.
 Auscultated Lower Right Back Infant Well Visit Zachary LaFontaine Shadow health Transcript

Exam Action
05/28/22 2:41 AM EDT

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