Subjective: Patient ID is a 6 wk.o. male infant who is here for

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

Share This Post

Email
WhatsApp
Facebook
Twitter
LinkedIn
Pinterest
Reddit

Order a Similar Paper and get 15% Discount on your First Order

Related Questions

Help responding to collegues Please respond to the following colleaguesAS Angela

Help responding to collegues  Please respond to the following colleagues AS Angela Stapleton-Burley Jun 25 10:56pm Manage Discussion by Angela Stapleton-Burley Reply from Angela Stapleton-Burley   Hi Everoyne, One significant benefit of incorporating big data into clinical systems is the enhancement of predictive analytics, which allows providers to proactively identify

Purpose: The purpose of this assignment is to assess your ability to conduct a systematic and comprehensive head-to-toe physical assessment. This will

Purpose: The purpose of this assignment is to assess your ability to conduct a systematic and comprehensive head-to-toe physical assessment. This will help reinforce critical thinking, clinical reasoning, and documentation skills essential for nursing practice. By completing this assignment, you will demonstrate proficiency in assessing various body systems, identifying normal

COMPLETE USING DOCUMENT POSTED WITH ASSIGNMENTThumbnails/thumbnail.pngDetermining Anesthesia Service Payments and Modifiers As a new medical

COMPLETE USING DOCUMENT POSTED WITH ASSIGNMENT Thumbnails/thumbnail.png Determining Anesthesia Service Payments and Modifiers As a new medical coder for an Anesthesiologist group, it is important that you practice calculating service payments by assigning the appropriate anesthesia code(s) and modifier(s), as well as determining the base and time unit values, any

COMPLETE ALL QUESTIONSThumbnails/thumbnail.png1) The ICD-10-CM Official Guidelines for Coding and Reporting are approved by the FILL IN

COMPLETE ALL QUESTIONS Thumbnails/thumbnail.png 1) The ICD-10-CM Official Guidelines for Coding and Reporting are approved by the FILL IN BLANK  parties for ICD-10-CM to accompany and complement the official conventions and instructions provided within ICD-10-CM. 2) Official coding guidelines use the term FILL IN BLANK  when referring to face-to-face contact between patients and health

  Questions Discussion Board: Instructions Purpose: The purpose of this assignment is to familiarize you the complexity of quantitative statistical

  Questions Discussion Board: Instructions Purpose: The purpose of this assignment is to familiarize you the complexity of quantitative statistical analysis. Instructions: For this discussion, please complete the following: Review the assigned chapters in Polit and Beck (2017): i.e., chapters 18-20. Identify five different facts or pieces of information that