NU 6541 WEEK 10 SOAP NOTE Gastroesophageal Reflux Disease

Gastroesophageal Reflux Disease Cindy Clifton Walden University NU 6541 Primary Care of Adolescents and Children July 30, 2018 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