Office Visit Note
Narrative: --- SUBJECTIVE: **Chief Complaint:** Weight check and cardiac evaluation at 5 days of life. **History of Present Illness:** Five-day-old female presenting for routine newborn follow-up. Infant had transient tachypnea for 3 days immediately postpartum with unremarkable exam at that time; respiratory symptoms have completely resolved. Newborn screening identified a borderline pulse oximetry result. Additionally, infant failed newborn hearing screening in the right ear. Birth weight 8 lbs 10 oz; current weight 8 lbs 8 oz (appropriate weight loss for age). Parents report feeding well, adequate stooling and voiding, and sleeping appropriately. **Review of Systems:** No respiratory distress, no cyanosis, no poor feeding, no lethargy. Infant active and interactive. --- OBJECTIVE: **Physical Examination:** - **General:** Alert, active, well-appearing infant in no distress. Skin pink and well-perfused. - **Cardiac:** Regular heart rate and rhythm. No murmur. Good distal pulses bilaterally with strong perfusion. No signs of cardiac compromise. - **Respiratory:** Lungs clear bilaterally. Respirations unlabored and appropriate for age. No retractions or grunting. - **HEENT:** Anterior fontanelle soft and flat. Eyes clear. Nares patent. Ears externally normal. --- ASSESSMENT: 1. **Borderline newborn pulse oximetry screening** (ICD-10: Z13.4) Five-day-old with borderline result on critical congenital heart disease screening. Physical exam today is entirely reassuring with no murmur, normal heart rate and rhythm, good perfusion, and no respiratory compromise. Will pursue watchful waiting approach; echocardiogram to be considered only if new symptoms develop (increased respiratory distress, cyanosis, poor feeding, or lethargy). 2. **Unilateral hearing screening failure, right ear** (ICD-10: Z01.110) Infant failed newborn hearing screening in right ear. Requires audiology referral for repeat testing per Early Hearing Detection and Intervention protocol. 3. **Resolved transient tachypnea of newborn** (ICD-10: P22.1) History of tachypnea for 3 days postpartum with normal exam. Symptoms completely resolved; no respiratory distress on exam today. --- PLAN: Reassured parents that today's cardiac exam is completely normal and that borderline pulse oximetry screening results are common and often do not represent significant cardiac disease. Will monitor clinically and will obtain echocardiogram if any concerning symptoms develop (increased work of breathing, cyanosis, poor feeding, decreased activity). Parents counseled on red flag symptoms warranting urgent evaluation. Audiology referral placed for repeat hearing screening and formal audiologic evaluation per EHDI guidelines; follow-up testing to be scheduled. Given anticipatory guidance on newborn care including proper feeding technique, safe sleep environment (supine, firm surface, room-sharing without bed-sharing), avoidance of overheating, and signs requiring urgent care (fever, feeding difficulties, lethargy, respiratory distress, cyanosis). Routine newborn care and follow-up with primary pediatrician in 3-5 days or sooner if concerns arise. Parents instructed to contact office with any questions or if new symptoms develop. **CPT:** 99461 (newborn evaluation/management) --- REFERENCES: 1. Kemper AR, Mahle WT, Martin GR, et al. Strategies for implementing screening for critical congenital heart disease. *Pediatrics*. 2011;128(5):e1259-e1267. 2. American Academy of Pediatrics, American Speech-Language-Hearing Association, Directors of Speech and Hearing Programs in State Health Agencies. Joint Committee on Infant Hearing 2007 Position Statement. *Pediatrics*. 2007;120(4):898-921. 3. American Academy of Pediatrics Committee on Fetus and Newborn. Hospital stay for healthy term newborns. *Pediatrics*. 2023;151(2):e2022057990. --- CODES: CPT 99461 | ICD-10 Z13.4, Z01.110, P22.1 [routine normal findings assumed unless specified]