Shadow Health Assignments
Zachary LaFontaine Shadow health Objective data
My Provider Notes
Student Documentation Model Documentation
Subjective
This is a healthy 2-month-old baby who came to the appointment with the mother. The mother reports that the baby’s feeding and sleeping patterns are normal. The baby interacts well socially, and there are no concerns about vision or hearing. Safety measures at home include smoke detectors and a safe sleeping environment. The baby’s hygiene, particularly the diaper area, is in good condition.
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A 2-month-old male baby is here for a check-up. He was born vaginally at 39 weeks gestation and had no complications at birth. His current weight is 7 pounds 4 ounces and his length is 19 inches. He is breastfed about 5-7 times a day for around 10 minutes per breast. He has about 5-6 wet diapers and 3 bowel movements per day. He sleeps about 16 hours on certain days and wakes up more often on other days. He is developing well, smiling, tracking objects, and lifting his head when on his tummy. The mother is busy with school and has help caring for the baby. She eats healthily but doesn’t always get sufficient sleep. The baby’s safety measures are in place, including a rear-facing car seat and a safe sleeping environment.
Objective
The baby’s growth is normal, with his head circumference, weight, and length all falling between the 5th and 95th percentiles. Vital signs are within normal limits. Physical examination reveals no abnormalities in the nose, ears, mouth, or 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
The baby is calm and alert during the examination. His head is symmetrical, fontanelles are smooth and flat, eyes and ears are normal. The nose and mouth show no abnormalities. The neck has full range of motion. His breathing is even and his lungs are clear. The cardiovascular system is normal with regular heart sounds. The abdomen is soft and non-tender. Genitalia and extremities are normal. The baby’s reflexes and skin condition are all within normal range.
Assessment
The baby’s development, growth, and overall health are all normal for a 2-month-old baby. There are no concerning findings in the examination.
Plan
The baby should continue breastfeeding. The next appointment is in 2 months unless there are any concerns. The mother’s health should be monitored, including physical and mental well-being. Vaccinations should be administered as per CDC guidelines.
For the next visit, the baby will receive vitamin D drops daily and continue breastfeeding. A structured feeding schedule should be developed to supplement breastfeeding when the mother is at school. Consultation with a lactation specialist is recommended. Safety measures should be maintained, and vaccines administered during this visit. The baby’s developmental milestones and cues for sleep should be attended to. Parental self-care, reading, and interaction with the baby are important. Nutrition and safety guidelines should be followed.
(Note: The content has been paraphrased while retaining the main points and medical information.)
My Provider Notes
| Student Documentation | Model Documentation |
|---|---|
SubjectiveThis is a well nurished 2 month infant, at the appointment with mother. Mom reports normal feeding and sleeping patterns. Interacts socially. Seems to have vision and audition normal. Safety measures at home, smoke detectors, safe at the place to sleep, cnstant supervision of an adult. Hygiene of infant is good, diaper area normal. |
2 month old male infant today for child check. Birth information male infant born via vaginal delivery at 39 weeks gestation. Length-19”, Weight-7lbs 4 oz, APGAR 9@ 1 min, 10 @ 5 min. There were no birth complications. Here today accompanied by his mother. Medications: Currently not taking any medications, No known medication allergies Nutrition: Breastfeed 5-7 feeds/day about 10 min each breast, schedule varies by day due to mothers school schedule Elimination: Spitting-minimal, 5-6 wet diapers a day, 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. 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. Reports she does eat a healthy diet and drinks plenty of water. Does report insufficient sleep. Reported breasts feel full before feeding and don’t always feel empty after feeding. Denies any breast leaking. Safety: Car seat is rear facing in the 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. |
ObjectiveNormal growing curves: Head circ, wt and length, all above 5 and under 95 percentile. Vital signs WNL Nose, ears, mouth and skin, WNL, no abnormal findings. |
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 with full ROM, lags when lifting body Resp: Symmetrical chest rise and fall, smooth even respirations, bilateral lungs clear to auscultation, CV: Regular 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, Barlow and Ortolani negative. Neuro: Active, alert, sucking, rooting reflex intact, moro reflex intact, stepping reflex intact, tonic reflex intact and symmetrical, 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 |
AssessmentNormal findings for a 2 months old male baby. Head with normal development, normal size, and growing speed. Well nurished. No abnormal findingds on cardiopulmonary systems. Ortho: Barlow and Ortolani were normal, no Signs pf hip problems. Moro reflex normal for the age. Milestones within age for normal development. |
Well child check Feeding difficulties |
PlanContinue breastfeeding. Appointment in 2 months, unless needed before for abnormal findings. Monitor mother health, physical and mental. Vaccination as per CDC. |
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 back to sleep, Vaccines administered today-HepB, RV, DTaP, PCV13, IPV and HiB. Your infant may be 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: 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. 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. Anticipate 5-6 wet diapers a day and 3-4 stools per day. Continue your prenatal vitamin and a healthy diet. Safety: Continue with rear-facing infant seat in the backseat. Set your water heater to 120 degrees F. Do not leave your infant alone. As he begins to roll, you will need to keep a hand on him when on the changing table, etc. Dont wait until the last minute.Provide your requirements and let our native nursing writers deliver your assignments ASAP. |