Medical Terminiology:
Patient is a 2-day-old male who comes in with his mother for hisfirst visit after birth. He was a full-term infant, vaginallydelivered. Mother provides prenatal history, family historyincluding the paternal Rh factor and information regardinginherited red cell defects. The mother says the he has been “veryfussy” lately. The baby weighed 5 lb. 7 ounces. His temperature was98.6 degrees. His skin was yellowish in coloration, includingsclera. The physician conducted tests which included direct andindirect bilirubin levels. Further tests revealed gram-negativebacterial infection and serum bilirubin levels at 7mg/dl. Thephysician did blood tests for both the mother and the infant forblood group incompatibilities, hemoglobin levels, the directCoombs’ test, and hematocrit. After reviewing the data, thephysician felt that the patient has hyperbilirubinemia which wasdue to gram-negative bacterial infection. The physicianadministered an injection of albumin (1g/kg of 25% salt-pooralbumin), antibiotics given for the infection and the physicianalso asked that the mother bring the infant in three days so thathe could monitor the progress.
Rewrite the information in a SOAP note format.
