Office Visit Note
Narrative: CHIEF COMPLAINT Well child visit with feeding concerns, possible reflux, and weight check HISTORY OF PRESENT ILLNESS Pupus presents for a well child visit and weight check. Mother reports ongoing feeding challenges with a combination of breastfeeding and supplementation. They have been doing 4 ounces of supplement in addition to breastfeeding, but the infant is getting fussy around supplement time. Mother notes it is a confusing balance and she feels he is hungry. The infant has been pooping excessively per parent report. There is concern for reflux and spitting up. Mother's PA friend who works in the ED had suggested the possibility of pyloric stenosis, though noted it usually presents earlier. The clinician discussed the option of an upper GI study to evaluate for anatomic causes of reflux. REVIEW OF SYSTEMS GI: Excessive stooling per parent. Spitting up/reflux noted. Fussiness with feeding/supplementation. Denies vomiting concerns raised (pyloric stenosis discussed but not confirmed). General: Well-appearing, active, happy per observation. PHYSICAL EXAM General: Well-appearing, happy infant. Good hydration with visible saliva and tears. Skin: Capillary refill brisk. Weight: Up from last visit. Overall appearance described as looking great and well-hydrated. ASSESSMENT 1. Well child visit – weight is up from last visit, well-hydrated, well-appearing infant. 2. Feeding difficulty with breastfeeding and supplementation – mother reports fussiness around supplement feedings and difficulty balancing breast and bottle feeding. Weight gain is adequate and possibly slightly above target. 3. Possible gastroesophageal reflux – concern for significant reflux; upper GI study discussed to evaluate anatomy. Pyloric stenosis was raised by mother's friend but typically presents earlier. 4. Excessive stooling – noted by parent, to monitor. PLAN 1. Well child visit: Weight is trending up appropriately. Infant is well-hydrated with good capillary refill, tears, and saliva production. Continue to monitor growth. 2. Feeding: Weight gain suggests infant may be getting slightly more than needed. Will discuss adjusting supplementation amount. Continue breastfeeding with supplementation but consider reducing supplement volume slightly given adequate weight gain and fussiness. 3. Reflux evaluation: Upper GI study recommended to evaluate for anatomic abnormality contributing to reflux symptoms. The study involves the infant drinking a contrast substance that can be visualized on X-ray. Pyloric stenosis was discussed; while it typically presents earlier, it remains in the differential. Will proceed with upper GI. 4. Excessive stooling: Monitor; may be related to feeding volume. Reassess after any feeding adjustments. FOLLOW-UP Follow-up after upper GI study results are available; sooner if symptoms worsen including projectile vomiting, decreased wet diapers, or poor feeding. ICD-10 CODES Z00.121 - Encounter for routine child health examination with abnormal findings K21.0 - Gastro-esophageal reflux disease without esophagitis CPT CODES 99391 - Preventive visit, established patient, infant (age < 1 year) ───────────────────────────────────────── CODES: CPT 99391 | ICD-10 Z00.121, K21.0