Subjective

A two months old male infant is brought to the clinic by his mother child check. He breastfeeds 5-7 times a day due to mother’s busy schedule. He has 3 bowel movements and urinates 5 to 6 diapers a day Zachary LaFontaine Shadow health Documentation.

2 month old male infant today for child check. Birth information male infant born via xxx weeks gestation. Length-19”, x. There were no birth complications. Here today accompanied by his mother. Medications: Currently not taking any medications, No known medication allergies Nutrition: Breastfeed xx 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: Reports infant smiles, tracks objects with his eyes, coos, turns to noises and familiar sounds. Able to lift his head when on his tummy Zachary LaFontaine Shadow health Documentation. 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. xxx 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.

Objective

Vital signs: xx and calm infant Respiratory: lungs clear to auscultation, even and smooth respiration, symmetrical chest rise and fall. CV: S1, S2 present, no murmurs. Regular rate and rhythm

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 withxxx 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, xxx, 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 Shadow health Documentation

Assessment

Well child exam Feeding problems

Well child check Feeding difficulties

Plan

Prescribexxx daily Establish a feeding schedule and use a breast pump. Consult with lactation specialist Follow up in 3-4 weeks for weight check

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 xxxbe 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: Zachary LaFontaine Shadow health Documentation 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. 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. Parent 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 Zachary LaFontaine Shadow health Documentation. 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. xxxgins to roll, you will need to keep a hand on him when on the changing table, etc.