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focus note

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

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