Office Visit Note
Narrative: CHIEF COMPLAINT Recurrent projectile vomiting over the past 6-8 weeks with history of reflux HISTORY OF PRESENT ILLNESS Beacon is a young male with a history of reflux on antacid therapy who presents for evaluation of recurrent vomiting that began approximately 6-8 weeks ago and has become increasingly consistent. Parent reports emesis occurring typically once daily at variable times of day, with no consistent pattern related to time, location (home vs daycare), or positioning. The emesis is described as large volume and forceful — not truly projectile (unable to hit a wall) but significant. The vomitus has appeared yellow in color on at least one occasion; no green/bilious emesis reported. Parent notes the child typically shows prodromal signs approximately 5 minutes before vomiting, including fussiness and back arching. The child appears happy and comfortable after vomiting episodes. Parent reports the vomiting seems to occur more with larger bottle volumes (e.g., 6 oz vs 3 oz) and has not occurred with solids alone — episodes seem to involve liquid feeds, sometimes followed by purees. Over the most recent week, Friday through Monday the child vomited once daily, took Tuesday off, then had a large episode last night after a bottle followed by mango puree. The child has also shown decreased interest in his bottle over the past week or so, intermittently refusing after 2 ounces. He has been on antacid medication consistently for approximately 2 weeks without notable improvement in discomfort. The family recently switched from Bobbie Original formula to Bobbie Gentle (partially hydrolyzed, lower lactose) approximately 2.5 days ago; the one vomit-free day coincided with the formula change, but vomiting recurred last night. The child has had one episode of vomiting in his crib but this is not a consistent pattern. Parent notes the child seems to vomit more frequently in a seated/flexed position. The child has also been drooling and teething. He was recently exposed to a cousin diagnosed with croup over the Fourth of July. He currently wears a cranial helmet for plagiocephaly, managed through Shriners. REVIEW OF SYSTEMS Denies fever. Denies blood in stool. Denies rash. Denies abnormal stools. No signs of dehydration noted by parent. Drooling and teething reported. Denies throat-burning symptoms or significant discomfort with reflux. Decreased bottle intake noted intermittently. Recent exposure to croup, but no respiratory symptoms reported. MEDICATIONS REVIEWED Antacid (specific agent not named) — restarted and taken consistently for approximately 2 weeks. No notable change in discomfort reported with medication use. PHYSICAL EXAM General: Well-appearing, well-hydrated infant. Alert, interactive, happy. Wearing cranial helmet for plagiocephaly. Weight: increased from prior visit (16.5 lb previously); however, weight percentile has decreased from approximately 30th to approximately 20th percentile (historically has ranged from 20th to 60th percentile). No acute distress. No emesis observed during visit. ASSESSMENT 1. Recurrent vomiting — once daily, large volume, over 6-8 weeks in an infant with known reflux. No bilious emesis, no hematemesis, no bloody stools, no rash, no dehydration. No consistent pattern identified to suggest obstruction or food allergy. Weight percentile has decreased modestly (30th to ~20th) but child continues to gain weight. Prodromal fussiness and back arching suggest gastric distention/reflux as a contributing mechanism. Not currently meeting threshold for laboratory evaluation given overall well appearance and adequate hydration. 2. Gastroesophageal reflux — on antacid therapy for approximately 2 weeks without notable symptomatic improvement. No signs of significant esophageal irritation or pain-predominant reflux. 3. Decreased bottle intake — intermittent, refusing after 2 ounces at times. Possibly related to reflux or gastric discomfort. 4. Plagiocephaly — currently in cranial helmet (3D-printed, via Shriners). Parent reports doing well with it. History of preferential head positioning during a period when the rest of the family was ill. 5. Teething/drooling — age-appropriate, reassured that drooling and teething are normal and unrelated to the vomiting. PLAN 1. Recurrent vomiting/reflux: Recommended smaller, more frequent bottle feeds to reduce gastric distention and minimize reflux-triggered emesis. Advised the family to keep a detailed intake log documenting bottle volumes, timing, type of feed (formula vs solids), specific foods, and vomiting episodes to identify potential triggers. Encouraged making only one change at a time and allowing 3-5 days per change to assess effect. Continue current antacid therapy. No laboratory studies indicated at this time given adequate hydration and weight gain. Discussed that yellow vomitus is consistent with stomach contents and not bilious. Discussed red flags warranting prompt reevaluation: increasing frequency of vomiting, bilious (green) emesis, blood in stool or vomit, signs of dehydration (decreased wet diapers), worsening discomfort or pain symptoms, or failure to gain weight. If the child is sent home from daycare for reflux-related emesis, the family may request a note clarifying this is a known medical condition (reflux) and not an infectious illness. 2-3. Reflux/decreased intake: Continue current antacid. Monitor intake closely as part of the tracking log. Continue trial of Bobbie Gentle formula as the current variable being tested. 4. Plagiocephaly: Continue cranial helmet as directed by Shriners. 5. Teething: Reassurance provided; no intervention needed. FOLLOW-UP Follow up once the family has collected intake and emesis tracking data to review for patterns; sooner if red flag symptoms develop. ICD-10 CODES K21.0 - Gastro-esophageal reflux disease with esophagitis K21.9 - Gastro-esophageal reflux disease without esophagitis CPT CODES 99213 - Office visit, established patient, low complexity MDM ───────────────────────────────────────── CODES: CPT 99213 | ICD-10 K21.0, K21.9