Archer Cohen iHuman ( SOAP Notes) 3-days-old follow up for Jaundice 

The mother presents to the office today with her son Archer for a follow-up for jaundice. Generalized skin jaundice was noted on the second day of life in the newborn nursery, and the mother stated she noticed “yellow eyes” this morning. The total bilirubin level at discharge yesterday was 12 mg/dL, which is in the high intermediate risk zone. The infant has lost 54 grams over the past 24 hours. The infant has also had a decrease in wet diapers since yesterday, now averaging 4-5 per day, previously 5-6 per day. The child is stooling normally, about 2-3 times per day. The child has been breastfed exclusively since birth; however, the mother’s milk supply is not established. States she was instructed to start supplementing with formula but expresses fear toward supplementation. The mother is unsure of how much the infant is eating per day. Mother states that he is very fussy. Archer has not had any treatments for his jaundice as of now. Jaundice of the skin was noted on day 2 of life. Scleral jaundice was noted today, on day 3 of life. The newborn has lost 54 grams in the past 24 hours. Decrease in wet diapers (5-6 per day, now down to 4-5 per day). Newborns are exclusively breastfed; however, the mother is not making much milk, therefore, he is not feeding “too well.” No change in vital signs from yesterday. Bilirubin level at 48HOL: Bilirubin, total: 12 mg/dl. Bilirubin, direct: 0.8 mg/dl. No jaundice within 24 hours of delivery. No nausea or vomiting. Normal CBC w/ diff. No fatigue or lethargy. Normal Hgb/Hct.