S- The patient is 4months 2 weeks old and information was given to his mother through the interpreter. The mother said the vomiting has stopped. She also said he is doing well. Dylan is taking the formula very well 4oz every 4 hours. Dylan is more constipation now and she was thinking of introducing water to him. Dylan can recognize the people around him. Dylan is able to reach his toes with his hands and evening holding his bottle. He is also stretching for toys.
O: Dylan’s house is very clean, and he was well dressed. After the assessment, he was ready to eat. He is sucking, biting on his fingers and drooling. Dylan has good head control and can put himself up when he is lying on his stomach.
A: Temp 96.5 weight 18 lbs., length 27inches, RR 32 HR 128. Posterior fontanelle close and anterior still open with suture intact. Mucous membranes moist, no mucosal lesions. Heart rate regular and rhythm, no murmur or gallop. Lung clear to auscultation and percussion bilaterally.
Abdomen Bowel sounds normal, no tenderness or masses. Genitalia uncircumcised penis, testes descended, no hernias, no scrotal masses. Skin good turgor, no rash or prominent lesions.
P: Stresses the important of iron-rich food, avoidance of sweets. formula during the day. The diaper size was too small so we have to bring it back to the center. We educated the mother about safety measures and injury prevention when the baby is playing with his toys. Discussed infant safety seat, smoke detector, hot water heater temperature, electric outlet cover, and toxic chemicals.