Office Visit Note
Narrative: CHIEF COMPLAINT 4-month well child visit HISTORY OF PRESENT ILLNESS This is a 4-month-old male infant presenting for his well child visit. Mother reports feeding is going "much, much better" compared to prior visits. He is primarily breastfed with some bottles of breast milk. He continues to spit up frequently — mother describes him as "just a puker" — but states it is "night and day" improved from before. He has declined the pacifier over the past couple of days. He is sleeping well, waking once per night to feed, which he has been doing since approximately 1 month of age. He is taking long naps. The family is using a Merlin Magic Sleep Suit, which he tolerates well. Mother asks about sleep training and solid food readiness. No acute concerns raised. Family is planning a move to Boston. REVIEW OF SYSTEMS Constitutional: No fever reported. Growing well, gaining weight. GI: Continued spitting up, improved from prior. Tolerating breast milk well. Skin: Mother mentions hair shedding; provider reassures this is normal at 3-4 months. Neuro/Development: Has laughed/giggled before, though not consistently. Active, kicking well during exam. MEDICATIONS REVIEWED Tylenol discussed for post-vaccination use. No ibuprofen until after 6 months. No routine medications noted. PHYSICAL EXAM General: Well-appearing, active infant. Alert and interactive. Kicking actively during exam. Growth: Weight 15.5 pounds, 45th percentile. Development: Vocalizing, active extremity movements, kicking observed. Has giggled previously per parent report. ASSESSMENT 1. Well child visit, 4 months of age 2. Spitting up — improved, consistent with infant who is a habitual spitter; weight gain is reassuring with weight now at 45th percentile 3. Sleep counseling — waking once nightly, age-appropriate; gentle sleep training discussed 4. Immunizations — Rotavirus dose 2 of 3 and Prevnar dose 2 of 4 administered 5. Solid food readiness discussion — parent inquired; not yet showing readiness per mother PLAN 1. Well child visit: Growth is reassuring with weight up to 45th percentile. Continue breastfeeding. Next well child visit at 6 months; subsequent visits at 9 and 12 months. Family transitioning care to Boston. 2. Spitting up: No intervention needed at this time. Weight gain is appropriate and symptoms are improving. 3. Sleep: Discussed gentle sleep training appropriate for age. Advised not to let baby fall asleep at the breast due to developing object permanence — he should be put down at least partially awake to learn self-soothing. If he wakes and fusses overnight, parents may allow 10-15 minutes of fussing to see if he self-settles, but not longer at this age. More assertive sleep training can be considered at 6 months. One overnight feed remains age-appropriate. Merlin Sleep Suit may continue until outgrown or up to approximately 9 months. 4. Immunizations: Rotavirus oral vaccine (dose 2 of 3) and Prevnar injection (dose 2 of 4) administered today. Counseled that fever, redness, and swelling at injection site are possible, and more likely with booster doses. Tylenol may be used for discomfort. No ibuprofen until after 6 months. 5. Solids readiness: Mother asked about starting solids. Could begin now but mother does not feel baby is ready. Discussed that most infants are not ready at 4 months and this can be revisited at the 6-month visit. ANTICIPATORY GUIDANCE Safety counseling provided: discussed fall risk as baby is now strong enough to roll off elevated surfaces. Advised car seat should be placed on the floor rather than on tables or counters, as infant can lurch and tip it. If placed on elevated surface, position in the center away from edges. Discussed risk of unplanned pregnancy while breastfeeding — mother has had return of menses and was counseled about contraception. Normal hair shedding at 3-4 months was discussed and reassured as physiological. Maternal nutrition discussed — multivitamin with iron recommended for mother; discussed sleep, healthy diet, and activity for maternal well-being. FOLLOW-UP 6-month well child visit; family transitioning care to a provider in Boston. Contact provider as needed in the interim. ICD-10 CODES Z00.129 - Encounter for routine child health examination without abnormal findings CPT CODES 99391 - Preventive medicine, established patient, infant (age under 1 year) ───────────────────────────────────────── CODES: CPT 99391 | ICD-10 Z00.129