Zachary LaFontaine Infant Well Visit Shadow health documentation

Zachary LaFontaine Infant Well Visit Shadow health documentation

My Provider Notes

Student Documentation Model Documentation

Subjective

Zachary LaFontaine Infant Well Visit Shadow health documentation

2 month old male infant today for child check. Birth information male infant born via vaginal delivery at 39 weeks gestation. Length-19”, Weight-7lbs 4 oz, APGAR [email protected] 1 min, 10 @ 5 min. There were no birth complications. Here today accompanied by his mother. Medications: Currently not taking any medications, No known medication allergies Nutrition: Breastfeed 5-7 feeds/day about 10 min each breast, schedule varies by day due to mothers school schedule Elimination: Spitting-minimal, 5-6 wet diapers a day, usually 3 bowel movement per day soft, mustard yellow in nature Sleep: Sleeping about 16 hours on Mon-Wed-Fri, Unknown number of hours of sleep on Tuesday and Thursday as her mother cares for Zachary on these days while she is at school. He does wake up more frequently at night on Tuesday and Thursdays Development and behavior: Zachary LaFontaine Infant Well Visit Shadow health documentation Reports infant smiles, tracks objects with his eyes, coos, turns to noises and familiar sounds. Able to lift his head when on his tummy. Maternal Health: Reports a very busy schedule. Attends school two days a week and her mother helps care for Zachary when she is at school. Reports she does eat a healthy diet and drinks plenty of water. Does report insufficient sleep. Reported breasts feel full before feeding and don’t always feel empty after feeding. Denies any breast leaking. Safety: Car seat is rear facing in the back seat, Back to sleep on a cradleboard or in the bassinet in mothers bedroom, Daycare-not enrolled at this time, cared for at home by relatives. Zachary LaFontaine Infant Well Visit Shadow health documentation

Objective

Zachary LaFontaine Infant Well Visit Shadow health documentation

Vital signs: Length=55.2 cm, Weight=4.39 kg, Head circumference=38.1 cm, Temp=36.2C, Heart rate= 132/min, Resp=36 breaths/min General: Infant in mothers arms, calm and alert HEENT: Head: symmetrical, Anterior fontanelle smooth, soft, flat, Posterior fontanelle smooth, soft, flat thin hair Eyes: open spontaneously, lens clear, red reflex present, PERRL Ears: ears aligned with palpable fissures, pinna flexible, lobe formed appropriately, turns head towards sounds Nose: Nares pink, patent, thin white mucus present Mouth/Throat: Palate intact, tongue with full ROM, smooth, frenulum intact, uvula midline Neck: Neck with full ROM, lags when lifting body Resp: Symmetrical chest rise and fall, smooth even respirations, bilateral lungs clear to auscultation, CV: Regular rate and rhythm, S1S2 present, no murmurs, Pulse present, equal bilaterally Abd: Abdomen protuberant, soft, nontender, bowel sounds normoactive, umbilicus healed GU: Scrotum with smooth rugae, circumsized penis with urethral meatus midline, testes present bilaterally MSK: Bilateral extremities symmetrical, moves all extremities freely, Barlow and Ortolani negative. Neuro: Active, alert, sucking, rooting reflex intact, moro reflex intact, stepping reflex intact, tonic reflex intact and symmetrical, grasp reflex intact Skin: Warm, smooth, congruent with genetic background. Elastic turgor. No lesions noted, mucous membranes moist, pink and intact. diaper area without any rash. Hearing/Vision: Eyes track objects. Turns head to familiar voice Zachary LaFontaine Infant Well Visit Shadow health documentation

Assessment

Normal findings for a 2 months old male baby. Head with normal development, normal size, and growing speed. Well nurished. No abnormal findingds on cardiopulmonary systems. Ortho: Barlow and Ortolani were normal, no Signs pf hip problems. Moro reflex normal for the age. Zachary LaFontaine Infant Well Visit Shadow health documentation Milestones within age for normal development.

Well child check Feeding difficulties

Plan

Continue breastfeeding. Appointment in 2 months, unless needed before for abnormal findings. Monitor mother health, physical and mental. Vaccination as per CDC. Zachary LaFontaine Infant Well Visit Shadow health documentation

Surveillance for next visit Vitamin D drops 400 IU 1 drop daily Continue with breastfeeding, develop a structured feeding schedule and begin using breast pump in between feedings so you have milk to supplement your infant when you are at school. Consultation with a lactation specialist to improve feeding practices, develop appropriate feeding schedules and provide support. Never leave unattended, Continue with back to sleep, Vaccines administered today-HepB, RV, DTaP, PCV13, IPV and HiB. Your infant may be a little fussy today and develop a low grade fever. Notify the office for any high fevers, vaccine site reactions, rashes. Call 911 if develops difficulty breathing Return for weight check in 3-4 weeks and then for 4 month old well child visit Anticipatory Guidance: Social Language & Self Help: Will begin to turn head towards familiar voices. Will look to parent to reassure him when he is upset. He will begin to associate you as the person who consoles him when he is upset. Zachary LaFontaine Infant Well Visit Shadow health documentation. Verbal Language: Will begin making extended cooing sounds. Will become more organized. Gross Motor: Will begin to support self on elbow and wrists. Encourage tummy time to build upper body strength and neck strength. Will begin to roll from stomach to back Fine motor: Will begin to notice he has fingers and will grasp objects with his whole hand. Pa Zachary LaFontaine Infant Well Visit Shadow health documentationrent and family health: Make sure you have your postpartum check up. Take time to care for yourself. Infant behavior: Hold, cuddle, talk and sing to your infant. It is a good time to start reading to help with brain development. Pay attention to your infant’s cues for sleep. Keep a schedule. Tummy time throughout the day when awake. Find calming techniques he will respond to. Important to never shake or hit your baby. Nutrition: It is too early for any food other than breast milk. Anticipate 5-6 wet diapers a day and 3-4 stools per day. Continue your prenatal vitamin and a healthy diet. Safety: Continue with rear-facing infant seat in the backseat. Set your water heater to 120 degrees F. Do not leave your infant alone. As he begins to roll, you will need to keep a hand on him when on the changing table, etc. Zachary LaFontaine Infant Well Visit Shadow health documentation