Blake Photo Time-Line

ONLC PEDIATRICS OCHSNER, BATON ROUGE REGION LA

Grondin, Blake John MRN: 12051461, DOB: 2/14/2020, Sex: M

Acct #: 72010283868 Enc. Date 3/10/2020

Progress Notes (continued)

Progress Notes by Lois H. Gesn, MD at 3/10/2020 11:00 AM (continued) Subjective:

History was provided by the grandmother and aunt.

Blake John Grondin is a 3 wk.o. male who was brought in for this well child visit.

Father in home? no

Current Issues: Current concerns include: none.

Review of Perinatal Issues: Known potentially teratogenic medications used during pregnancy? no

Alcohol during pregnancy? no Tobacco during pregnancy? no Other drugs during pregnancy? yes - Opiates, subutex, THC, xanax, zyprexa Other complications during pregnancy, labor, or delivery? yes - infant had opiate withdrawal requiring morphine rx Was mom Hepatitis B surface antigen positive? no

Review of Nutrition: Current diet: formula (Enfamil Gentlease) Current feeding patterns: 2 oz q 3 hours Difficulties with feeding? no Current stooling frequency: 3-4 times a day

Social Screening: Current child-care arrangements: in home: primary caregiver is grandmother Sibling relations: only child Parental coping and self-care: mother in rehab Secondhand smoke exposure? no

Growth parameters: Noted and are appropriate for age.

Review of Systems A comprehensive review of systems was negative except for: fussiness at night

Objective:

General: alert, appears stated age and no distress Skin: normal Head: normal fontanelles, normal appearance, normal palate and supple neck Eyes: sclerae white, normal corneal light reflex Ears: normal bilaterally Mouth: No perioral or gingival cyanosis or lesions. Tongue is normal in appearance. Lungs: clear to auscultation bilaterally Heart: regular rate and rhythm, S1, S2 normal, no murmur, click, rub or gallop Abdomen: soft, non-tender; bowel sounds normal; no masses, no organomegaly

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