Transcript/subjective data Toddler Sick Visit: GI. Zachary lafontaine 30 months

Transcript/subjective data Toddler Sick Visit: GI. Zachary lafontaine 30 months SUBJECTIVE . Identifying Data & Reliability: Ms. LaFontaine presents to the clinic with her 2-month-old son, Zachary (ZF). She agrees to be the historian today for her son’s physical assessment. Chief Complaint: Mom reports bringing Zachary in for a wellness visit. “It was hard to work it into our schedule, but I know it’s important.” History of Present Illness: Ms. LaFontaine reports that she is breastfeeding ZF. She denies using formula and admits to having a hard time finding enough time to breastfeed. When asked about pumping, she reports not being able to afford a breast pump. She feeds about 20 minutes at a time, every 2-3 hours during the day and every 3- 4 hours at night – 10 minutes per breast. She says her breasts feel full before feeding, but don’t always feel empty after feeding. She denies feeding ZF at the same time every day. She also denies breast and nipple pain, or frequent breast leaking. Allergies: Denies known allergies. Medications: None. Past Medical History: None. Subjective Data Collection: Ms. LaFontaine reports that she is ZF’s mother and primary caregiver, but she has some help from her mother as well. She works and is in school (class two nights per week), so her time is limited. She reports that “it’s been a lot.” She has not been sleeping sufficiently. She tries to eat a healthy, high-calorie diet. She reports a minimal support network outside of family and feels overwhelmed. ZF sleeps about 16 hours a day Monday, Wednesday, Friday, and the weekends. Mom does not know exactly how much sleep Zachary gets on Tuesday and Thursday, as her mother is the caregiver on these days. ZF sleeps in a cradleboard or an empty bassinet, swaddled on his back, in her room. She does not cosleep with Zachary. Mom reports that ZF smiles, tracks objects with his eyes, coos, turns to noises and familiar sounds, and can lift his head when on his tummy. OBJECTIVE ZF Vitals: Length: 55.2 cm Weight: 4.39 kg Head Circumference: 38.1 cm Temp: 36.2 degrees Celsius HR: 132 beats per minute RR: 36 breaths per minute Physical Exam: Head: Symmetrical. Anterior fontanelle palpated is diamond-shaped, soft, flat, approximately 2- 3 cm in width and 3-4 cm in length. Posterior fontanelle is triangle shaped 0.5-1 cm in size, soft, and flat. Eyes: open spontaneously, lens clear, red reflex present. PERRL. Nose - equal airflow noted on the opposite side with manual occlusion of each nare. Nares pink with clear drainage noted. Ears - appropriately aligned with external canthus of eyes bilaterally, appropriate size, pinna bends with little resistance. Mouth/Throat: Frenulum attached middle of mouth floor. Appropriate length and movements. Appears thin. Palate meets at the midline completely. Tongue appears smooth and uvula located at midline. CV: Pulse palpated equally bilaterally with normal amplitude. Regular rate and rhythm, S1S2 present, no murmurs. Skin: reveals skin tone pink, smooth, warm, and dry. Good turgor, no lacerations or wounds or lesions noted. Oral mucous membranes pink, intact, and with appropriate moisture present. GU: Diaper area reveals no skin breakdown, lesions, erythema, or edema. Genitalia inspection reveals smooth scrotum with urethra midline of circumcised penis. Palpation reveals bilateral testes present without any masses. MSK: Forward movement and adduction of bilateral hips smooth, no abnormal movement of hip joint appreciated. Abduction of bilat hips smooth without dislocation, no palpable click. Infant freely moves all extremities equally on each side. Neuro: Assessed grasp. Able to lift shoulders off table with expected head lag. Assessed Moro reflex: infant briskly abducts arms and legs symmetrically, then brings legs up against trunk. Assessed tonic reflex and neck range of motion. Assessed rooting reflex: infant turns head in direction of stimulus and opens mouth. Infant response with sucking motion. Tongue protrudes past lips. While holding the infant upright with feet touching the table, the infant steps up and down in place. Abd: Palpation of abdomen reveals compliant abdomen without notable masses or irregularities. Deep palpation does not elicit grimace or crying response from the infant. All 4 quadrants of abdomen are rounded, appropriate for age. ASSESSMENT (Diagnoses) Diagnosis: ICD-10-CM R63.30: Feeding Difficulties Rationale: “Feeding difficulties in babies may happen because of breastfeeding challenges.” “Other factors that may affect a baby’s ability to feed are stress (Rodriguez, 2019).” Both are major issues for Mom and Zachary. PLAN Continue with breastfeeding. Add vitamin D to ZF’s plan of care; drops 400 IU once daily. Develop a structured feeding schedule and educate Mom on pumping and where to get a reasonably priced pump for budget. Educate that it is too early for Zachary to have food other than breast milk & anticipate that he should have 5-6 wet diapers a day and 3-4 stools per day. Be sure Mom takes time for herself and has her postpartum checkup. Follow up with her on this. Return for Zachary’s weight check in 3-4 weeks and then for his 4-month-old well child visit. [Referrals] – Consult with a lactation specialist to improve feeding practices, develop appropriate feeding schedules, and provide support. References Rodriguez, A. (n.d.). How to tell if your baby has a feeding problem. How to tell if your baby has a feeding problem | Edward-Elmhurst Health. Retrieved February 1, 2022, from