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Neonatal Followup Clinic Report On Infant Patient

786 words - 4 pages

Michael was seen in the Neonatal Followup Clinic on November 14, 2013 at 4 months 11 days corrected age. As you may recall, Michael was born at 32 + 2 weeks gestational age with a birth weight of 1600 grams. His neonatal course was complicated by respiratory distress and CPAP for 8 days. He had some hyperbilirubinemia and rule out sepsis. There were issues with IV access and he was on TPN for 12 days and required a PICC line. He had cellulitis and excoriation of the right arm which resolved quickly. He had apnea of prematurity and was on caffeine during his stay and this discontinued some time prior to discharge. He was noted to have anemia and was put on iron and had reflux and was put on ranitidine. He was discharged home from hospital in June 2013.

Since Michael’s discharge home from hospital, his general health has remained stable with no major illnesses or hospitalizations. He is being seen regularly by his pediatrician Dr. Govan and remains well in terms of his level of activity and feeding behaviors. His immunizations are up-to-date and he is currently on Di-Vi-Sol and ranitidine.

In terms of his diet history, he was fed pumped EBM until 3 weeks ago and is now on Similac 36 ounces a day by bottle. He has been introduced to some infant cereals and takes pureed food with no chocking and no gagging. As mentioned previously, he is on vitamin D. He enjoys spoon feeding and has been sleeping through the night. He is cared for at home by his mother.

On physical examination today, he has a weight of 7.1 kg, at the 50th to 75th percentile, a height of 64 cm, between the 50th and 75th percentile, and a head circumference of 43, between the 50th and 75th percentile. The remainder of the general physical examination was unremarkable. Neurologically, tone and deep tendon reflexes were normal and no clonus was elicited.

Developmentally, Michael was seen by our occupational therapist, Kristina Tocek. In terms of his social skills, he smiles, maintains appropriate eye contact and has cooing. He does not have stranger anxiety and had some crying but was quite cooperative.

In terms of his gross motor skills, his AIMS score was 16, which is at the 50th...

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