NU 6541 WEEK 10 SOAP NOTE Gastroesophageal Reflux Disease

Week 10 SOAP note- Gastroesophageal Reflux Disease Patient Initials: ___AL____ Age: ___9 Week____ Gender: ___F____ SUBJECTIVE DATA: Chief Complaint (CC): Episodes of spitting up that have worsened, weight recheck History of Present Illness (HPI): Patient is premature, African American infant born 6 weeks early. Patient was vaginal delivery. Mother did not have problems during pregnancy. Patient seen 1 week ago for weight check due to prematurity. Mother stated at that time that patient was taking 60ml of Neosure formula every 2-3 hours but was spitting up a “good bit” of formula. Per mother, formula was coming out infant’s nose, causing infant to cry. Mother states that spit up does not appear to be curdled. Mainly occurs at night. Infant was switched to anti- reflux formula and told to come back today for weight check. Mother states that infant appears to be vomiting more but is still taking 60ml of formula every 2-3 hours. Infant has gained only 2 ounces over last week. Medications: none Allergies: NKDA Past Medical History (PMH): Preterm birth at 32 weeks gestation. Past Surgical History (PSH): none Sexual/Reproductive History: No sexual behavior. Patient is infant. Personal/Social History: Mother denies alcohol, tobacco, or drug use during pregnancy. Patient sleeps well. Patient drinks Neosure formula. Mother denies smoking in home. Immunization History: Patient received HiB vaccination at discharge from hospital after birth. Mother refused patient’s 2-month vaccinations due to personal beliefs. Significant Family History: Mother denies any health problems for her or father. Maternal grandmother has hypertension. Maternal grandfather has hypertension and diabetes. Paternal grandmother has no health problems. Paternal grandfather has hypertension, hyperlipidemia. Lifestyle: Mother is 20 years old, lives with patient’s father who is 22. Mother states that they attend local church. Patient lives with parents who stay in apartment in town. Mother does not work and is primary caregiver for infant. Father works at local furniture factory. Apartment has running water and electricity. Infant is mother’s first child. Father has previous daughter that does not live with them. Review of Systems: General: Patient is sleeping in mother’s arms during clinic visit. Patient eats 60ml of Neosure formula every 2-3 hours. Mother tried antireflux formula but spitting up worsened, so she stopped it yesterday. Patient has gained 2 ounces in last week. Mother states that spitting up occurs shortly after feedings, worse at night. Patient is now spitting up after every feeding. HEENT: Mother denies any concerns. States patient can hear, and responses to noises. Patient does spit up forcefully, occasionally with formula coming out of nose. Denies any trouble when eating, or congestion. Mother states that there is occasionally milk on patient’s tongue post feeding. Neck: Denies any signs tenderness, pain, or swelling. Breasts: Denies any signs of pain to chest area. Respiratory: Mother denies any signs of trouble breathing. Cardiovascular/Peripheral Vascular: Denies any swelling in extremities. Gastrointestinal: Mother states that patient eats full 60ml of formula every 2-3 hours. she is eating well, with no loss of appetite. Patient does spit up after every feeding now. Mother states that before the anti reflux formula, it occurred only every other feeding. Mother states that patient cries occasionally after spitting up. Denies any trouble with bowel movements. Genitourinary: Denies trouble with urination. Musculoskeletal: Patient is an infant, can not walk. Patient does move arms and legs per mother. Denies any tremors or jerking movements. Psychiatric: Mother denies any maternal depression, suicidal thoughts. Neurological: Denies changes in sleep patterns. States that she sleeps well at night, and wakes for feedings every 3 hours. Mother does put patient back to sleep after feedings. Patient is spitting up after feedings, causing her to cry. Mother states that she does not lay patient on her back immediately after feedings. Skin: Denies any rashes or sores. Hematologic: Denies any bleeding. Mother denies bleeding disorders. Endocrine: Denies any symptoms at this time.