Infant Well Visit Shadow health documentation
At this appointment, a well-nourished 2-month-old infant is accompanied by his mother. The mother reports normal feeding and sleeping patterns
Student Documentation Model Documentation
Subjective
At this appointment, a well-nourished 2-month-old infant is accompanied by his mother. The mother reports normal feeding and sleeping patterns. The infant interacts socially and appears to have normal vision and hearing. Safety measures are in place at home, including smoke detectors and a safe sleeping environment with constant adult supervision. The infant’s hygiene, especially in the diaper area, is good.
Today, a 2-month-old male infant comes for a child check. He was born via vaginal delivery at 39 weeks gestation, with a length of 19 inches and a weight of 7lbs 4 oz. His APGAR scores were 9 at 1 minute and 10 at 5 minutes, and there were no birth complications. The mother accompanies him today. The infant is not taking any medications and has no known medication allergies. He is breastfed 5-7 times a day, with each breast feeding lasting about 10 minutes. The schedule varies due to the mother’s school schedule. The infant has minimal spitting, has 5-6 wet diapers a day, and typically has 3 bowel movements per day, which are soft and mustard yellow in nature. The infant sleeps about 16 hours on Mon-Wed-Fri, but the number of hours of sleep on Tuesday and Thursday is unknown as the mother’s relatives care for him on those days while she is at school.
The mother reports that the infant smiles, tracks objects with his eyes, coos, turns to noises and familiar sounds, and is able to lift his head when on his tummy. The mother has a very busy schedule, attending school two days a week, and her mother helps care for the infant during those times. She reports eating a healthy diet and drinking plenty of water but admits to insufficient sleep. She also mentions that her breasts feel full before feeding and don’t always feel empty after feeding. She denies any breast leaking. The infant’s safety measures include a rear-facing car seat in the back seat, back-to-sleep position on a cradleboard or in the bassinet in the mother’s bedroom, and he is cared for at home by relatives, as he is not enrolled in daycare at this time.
Objective
The infant’s growth curves for head circumference, weight, and length are all above the 5th percentile and below the 95th percentile. Vital signs are within normal limits. No abnormal findings are noted in the nose, ears, mouth, and skin.
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: The infant is in his mother’s arms, calm, and alert.
HEENT:
Head is symmetrical, anterior fontanelle is smooth, soft, and flat, posterior fontanelle is smooth, soft, and flat thin hair.
Eyes are open spontaneously, with a clear lens and red reflex present, and the pupils are equal, round, and reactive to light.
Ears are aligned with palpable fissures, with flexible pinna and appropriately formed lobes, and the infant turns his head towards sounds.
Nares are pink, patent, with thin white mucus present.
Mouth/Throat:
The palate is intact, the tongue has full range of motion, smooth, with intact frenulum, and the uvula is midline.
Neck has full range of motion, and it lags when lifting the body.
Respiratory:
The chest rises and falls symmetrically, with smooth, even respirations, and both lungs are clear to auscultation.
Cardiovascular:
The heart rate is regular, S1S2 present, with no murmurs, and pulses are present and equal bilaterally.
Abdomen is protuberant, soft, and nontender, with normoactive bowel sounds and a healed umbilicus.
GU: The scrotum has smooth rugae, the circumsized penis has the urethral meatus midline, and testes are present bilaterally.
MSK: Both extremities are symmetrical, and the infant moves all extremities freely, with negative Barlow and Ortolani tests.
Neurological: The infant is active, alert, and demonstrates sucking, rooting reflex, moro reflex, stepping reflex, tonic reflex, and grasp reflex, all intact and symmetrical.
Skin is warm, smooth, congruent with genetic background, with elastic turgor. No lesions are noted, and mucous membranes are moist, pink, and intact.
The diaper area shows no rash. Hearing/Vision: The infant’s eyes track objects, and he turns his head to familiar voices.
Assessment
Normal findings for a 2-month-old male baby. The head shows normal development, normal size, and appropriate growth rate. The infant is well-nourished, and there are no abnormal findings in the cardiopulmonary systems. The Barlow and Ortolani tests were normal, with no signs of hip problems.
The Moro reflex is normal for the age, and milestones are within the expected range for normal development.
Well-child check Feeding difficulties
Plan
Continue breastfeeding. Schedule an appointment in 2 months, unless needed earlier for any abnormal findings.
Monitor the mother’s physical and mental health.
Administer vaccinations as per CDC guidelines.
Surveillance for the next visit.
Administer Vitamin D drops, 400 IU, 1 drop daily. Continue breastfeeding, and develop a structured feeding schedule. Begin using a breast pump in between feedings to have milk to supplement the infant when the mother is at school.
Consult with a lactation specialist to improve feeding practices, develop appropriate feeding schedules, and provide support. Never leave the infant unattended.
Continue with the back-to-sleep position. Administer vaccines today (HepB, RV, DTaP, PCV13, IPV, and HiB).
Expect the infant to be a little fussy today and develop a low-grade fever. Notify the office for any high fevers, vaccine site reactions, or rashes.
Call 911 if the infant develops difficulty breathing. Return for a weight check in 3-4 weeks, and then for a 4-month-old well-child visit.
Anticipatory Guidance:
Social Language & Self-Help: The infant will begin turning his head towards familiar voices and looking to his parent for reassurance when upset. He will start associating the parent as the person who consoles him when he is upset.
Verbal Language:
He will begin making extended cooing sounds and becoming more organized in his vocalizations.
Gross Motor: He will begin supporting himself on his elbows and wrists, so tummy time is encouraged to build upper body and neck strength. He will also start rolling from stomach to back.
Fine Motor: He will begin noticing his fingers and grasping objects with his whole hand.
Parent and Family Health: It is important for the mother to have her postpartum checkup and take time to care for herself.
Infant Behavior: Holding, cuddling, talking, and singing to the infant are encouraged to aid in brain development.
Pay attention to the infant’s cues for sleep and maintain a schedule.
Provide tummy time throughout the day when the infant is awake, and find calming techniques that he will respond to. It is essential to never shake or hit the baby.
Nutrition: It is too early for any food other than breast milk. Expect 5-6 wet diapers a day and 3-4 stools per day. The mother should continue taking her prenatal vitamin and maintain a healthy diet.
Safety: Continue using a rear-facing infant seat in the back seat of the car. Set the water heater to 120 degrees F to prevent burns.
Never leave the infant alone, especially as he begins to roll, and keep a hand on him when on the changing table, etc. Infant Well Visit Shadow health documentation
