Office Visit Note
Narrative: Patient Name: Greta Chief Complaint: The patient is a 13-day-old infant presenting for a well-child check. The mother reports the baby has been somewhat cranky, crampy, and at times twitchy. The umbilical cord detached three days prior and is still in the process of drying, which can take up to a week. The mother notes she has an oversupply of milk, which leads to the baby overeating and occasionally spitting up after feeding, as the baby does not know when to stop. Additionally, the infant did not pass the hearing screening in one ear and has a scheduled follow-up with audiology. Patient Infos Social History: The mother works in wind energy development, a field currently facing challenges with government attempts to cancel projects, even those 98% complete, leading to massive waste of resources. She notes that projects can take 5-10 years to build, and her company has only completed one project in five years. She is currently on maternity leave until December 1st. The father works from home. They describe themselves as 'super active people.' They recently completed a gut renovation of their home, which was originally built in 1926 or 1928. Family Dynamics: The parents appear to be in a supportive partnership. The father is actively involved in the consultation, asking questions and participating in the care of the baby. The doctor encourages this dynamic by suggesting they share feeding and care duties, emphasizing the importance of practicing "tagging in and out." Psychosocial Assessment: The parents are attentive and engaged, asking pertinent questions about their daughter's health and care. The doctor noted the mother's "twitchy" nature and emphasized the need for her to rest and take care of herself, especially since she had not left the house in over a week. They are proactive about seeking support and education, having attended birth classes at Bluma. Support System: The parents have a strong support system, which includes a doula and connections made through the Bluma community, where they attended birth classes and yoga. The doctor also mentioned a postpartum support person associated with Lakes Access. They appreciate the referral system that has helped them get connected with necessary support. Coping Mechanisms: The doctor advised the parents to practice "tagging in and out" to share caregiving responsibilities. It was suggested that the mother could use a hand pump instead of an automatic pump to create a small back stock of milk, allowing the father to handle some feedings (starting with 2-3 ounces, or about an ounce per kilo of weight per feed) and giving the mother an opportunity to rest. Mental Health History: The patient's maternal grandmother has a history of a couple of strokes, which the doctor noted as a factor to monitor. Housing and Financial Situation: The family lives in a renovated house, originally built in 1926 or 1928. They gutted the house and started over, choosing not to do any add-ons, appreciating its good original build and dry foundation due to its location on a hill. The mother works in wind energy development, and the father works from home. They demonstrate environmental consciousness by owning two electric cars and subscribing to community solar gardens (a mixed-use plan for solar and wind), for which they pay a premium to Excel Energy, prioritizing green energy over cost savings. Patient Education: The doctor provided guidance on several topics, including: - Umbilical cord care: Continue sponge baths until the cord is fully dry, as submerged baths can lead to issues if the baby has a bowel movement. - Managing spit-up: This is often due to overeating; parents should try timing feeds (e.g., a 10-minute feed instead of 15) to find the optimal duration and prevent the baby from overeating. - Temperature regulation: The importance of keeping the baby warm with a hat, as babies lose a lot of heat through their heads due to their different head-to-body ratio and poor blood flow regulation. However, parents should avoid over-bundling, as blankets can trap heat and make it difficult to assess if the baby has a fever. - Hemangioma (stork bite): Explained as a collection of blood vessels, typically growing most in the first 0-4 months. It should be monitored for any rapid changes in size or redness, especially since it is located over the spine. - Immunizations: Discussion included Tdap (received by mother during pregnancy for passive immunity), RSV vaccine (not received by mother), and Hepatitis B vaccine (not given to the baby as the mother is Hepatitis B negative, which is acceptable despite insurance metrics). - Baby's temperament: The doctor recommended the book "The Happiest Baby on the Block" for cranky babies, which discusses techniques like swaddling, shushing, and swaying, noting that Greta will likely need rocking and holding as she dislikes being laid flat. - Maternal health: The mother received a COVID shot a month prior, providing passive immunity to Greta. The doctor also inquired about CMV testing during pregnancy and advised the mother to gather all prenatal records for review. - Illness vs. Allergies: The doctor clarified that allergies do not cause fever, distinguishing them from illnesses like the current prevalence of COVID and ragweed allergies. Consultant Service Assessment of Needs: The parents require education on newborn care, including feeding strategies to manage spit-up, bathing techniques for a baby with a healing umbilical cord, understanding normal newborn behaviors and health concerns such as hemangiomas, and guidance on immunizations. Referrals to Community Resources: The doctor mentioned Bluma as a good resource for birth classes and yoga, and also noted a postpartum support person associated with Lakes Access (Anna, a doula and parent baby support person). Treatment Planning: The primary plan is to monitor the red spot (hemangioma) at the base of the baby's spine. The doctor noted that if it grows quickly, an ultrasound may be necessary to ensure it doesn't extend deeper into the spine. Potential treatments, if needed, could include topical medicine to slow growth or laser therapy to destroy tissue. The parents are to continue with their scheduled audiology appointment. Prognosis: The baby is doing well. She is gaining weight appropriately, now weighing 6 pounds, 6 ounces (almost six and a half pounds). The doctor reassured the parents that she is a healthy baby, stating, 'She's great already,' and will be fine with two adults looking out for her. Follow-up Plan: The family will follow up with a scheduled audiology appointment on the 16th at Park Nicollet for the failed hearing screen. The doctor will check in with the family via text in 5-7 days to ensure things are going well, and another in-person visit is scheduled for a couple of weeks. The doctor also provided guidance on when to call (emergencies, on the fence about 9-1-1) versus texting (not for emergencies or middle-of-the-night calls). Recommendations: Consultation Recommendations - The doctor recommended a follow-up visit in a couple of weeks to monitor the baby's growth and the hemangioma. - A text message check-in is planned for 5-7 days to ensure things are going well. Referral Recommendations - The parents were advised to proceed with their scheduled appointment with audiology at Park Nicollet on the 16th due to the failed hearing test in one ear.