Subjective: |
Patient ID is a 6 wk.o. male infant who is here for
Chief Complaint | |
Patient presents with | |
• | Gastrophageal Reflux |
ANY SEPARATE IDENTIFIABLE PROBLEMS:
Vomiting after feeding, fussiness
History of Present Illness:
Mom says child has been having spit up and vomiting after almost each feed.
Timing of vomiting/spit ups: no
Weight changes: no
Aggravating factors: None
Relieving factors: None
Associated symptoms: see above
Child has special health care needs:
None
Review of Systems:
HEENT: neg
Respiratory: neg
Cardiovascular: Negative.
Genitourinary: Negative.
GI: see above.
Musculoskeletal: Negative.
Skin: neg
Neurological: Negative.
Endo/Heme/Allergies: Negative.
Psychiatric/Behavioral: Negative.
Allergies:
Reviewed
Family History:
Reviewed
Psychosocial:
Reviewed
Passive Smoking:
None
Objective: |
Physical Exam ( Pertinent findings related to problems are in bold):
Temp 98.4 °F (36.9 °C) (Temporal) | Wt 11 lb 4.5 oz (5.117 kg)
GENERAL: Appears well-developed.
HEAD: AFOF soft & flat, normocephalic
EYES: Conjunctivae and EOM are normal. Pupils are equal and reactive to light
EARS: Normal
NOSE: Normal
Mouth/Throat:
Mucous membranes are moist, no thrush, no blisters
Neck: Normal range of motion, supple.
CV: regular rate & rhythm, S1 and S2 normal, Pulses palpable, perfusion normal.
RESP: Effort normal & breath sounds normal, air entry clear/= bilaterally
ABD:
Soft, Bowel sounds are normal, No masses
GU: normal male genitalia
MS: Normal range of motion. Joints are normal.
SKIN: Normal.
NEURO: Active and alert; good tone and normal reflexes.
Assessment and Plan: |
Assessment: child is an 6 wk.o. male infant
1. | Gastroesophageal reflux disease without esophagitis | famotidine (PEPCID) 40 mg/5 mL (8 mg/mL) suspension |
|
PROBLEM ORIENTED PLAN:
GERD:
– Famotidine PO once a day
– Small feeds and good burping
– Keep head side about 20-30 degree up
– Call back if symptoms do not improve or get worse
Parents were given education and teaching about GERD and feeding issues.
Parents verbalized good understanding about condition and plan of care.
Follow up/next visit: As scheduled and PRN
