Office Visit Note
Narrative: CHIEF COMPLAINT 2-week well child visit with concerns about jaundice, head preference to the right, goopy eye, accessory nipple, ear cartilage variant, and gassiness HISTORY OF PRESENT ILLNESS Gus is a 2-week-old male presenting for his well child visit. He was born at 38 weeks with a birth weight of 8 lbs 14 oz. He is exclusively breastfed. Mother reports breastfeeding is going well; the baby has a good suck and appears satisfied after feeds, though he does not nurse for very long. He feeds approximately every 2-3 hours, though today went 3 hours between feeds without waking. Mother has not been pumping to avoid oversupply, as she experienced that with her first child. She can hand-express approximately 1 ounce with 10 pumps. The baby is having 2-3 larger bowel movements per day with small smears at other feeds, decreased from the high-volume stools in the first few days of life. Vitamin D drops are being administered via the nipple. Parents note jaundice that they feel has improved since they previously discussed it with the provider. They have observed a head preference to the right. The left eye has been goopy with yellow discharge over the past 24 hours, though it appeared improved at the visit. Mother identified a small spot below the left nipple that she had not previously noticed. Parents also noted a small white cartilage bump in one ear that is not present on the other side. The baby had a couple of days of significant gassiness with inconsolable discomfort; mother wondered if her dairy intake could be contributing. Circumcision is scheduled for the following day at the obstetrician's office. The umbilical cord stump appears to have come off early, with residual scab noted. Mother reports she is getting some rest when both children nap simultaneously and has started getting outside for walks in the last 2 days. REVIEW OF SYSTEMS Feeding: Breastfeeding well, appears satisfied after feeds. Stool pattern: 2-3 good stools daily with smaller amounts at other feeds. Skin: Peeling/molting noted. Jaundice noted, improved. Eyes: Goopy left eye with yellow discharge, improved today. GI: Several days of significant gassiness with inconsolable discomfort, now resolved. Sleep: Sleeping well between feeds. Activity: Age-appropriate. MEDICATIONS REVIEWED Vitamin D drops administered via nipple during breastfeeding. PHYSICAL EXAM General: Well-appearing 2-week-old male. Alert. Weight: 9 lbs 6 oz (above birth weight of 8 lbs 14 oz, demonstrating appropriate weight gain). Skin: **Mild jaundice noted.** Normal newborn desquamation (molting) present. Umbilical cord site with residual scab, healing appropriately. HEENT: **Left eye with mild discharge consistent with nasolacrimal duct obstruction, improved at time of exam.** Right ear with small cartilage variant (Darwinian tubercle-type bump), not present on opposite side. Mother has auricular pits and bilobed tragus; variant appears familial. Chest: **Accessory nipple noted below the left nipple.** Musculoskeletal/Neuro: **Head preference to the right noted.** Genitourinary: Normal male genitalia; uncircumcised (circumcision planned for the following day). ASSESSMENT 1. Well child visit, 2-week-old male — weight gain appropriate, now above birth weight. Breastfeeding well established. 2. Neonatal jaundice — mild, improving, expected to take a couple of months to fully resolve. 3. Head preference to the right — early positional preference noted; no flattening documented at this time. 4. Nasolacrimal duct obstruction, left eye — mild goopy discharge, improved; no signs of infection currently. 5. Accessory nipple, below left nipple — incidental finding, benign. 6. Ear cartilage variant, right ear — small cartilage bump, likely familial, benign. 7. Newborn gassiness — transient episode over a couple of days, self-resolved; not attributable to maternal diet at this time. 8. Breastfeeding counseling — mother with concerns about feeding frequency and stool pattern. PLAN 1. Well child: Weight gain is excellent. No vaccines today; vaccines will begin at the 2-month visit. Parents prefer individual component vaccines (ActHIB and Daptacel) rather than combination vaccines, based on experience with older sibling who had significant eczema temporally related to combination vaccines. Provider will attempt to order individual ActHIB and Daptacel, possibly through a local pharmacy for single-dose availability. Discussion of vaccine scheduling and splitting approach to be continued at the 2-month visit. 2. Jaundice: Reassurance provided that mild jaundice at this age is normal and expected to take a couple of months to fully fade. No further workup indicated at this time. 3. Head preference to the right: Parents counseled to be intentional about holding and burping the baby on both sides, alternating positions to counteract the natural tendency to favor the dominant hand side. During sleep, slight positioning to favor the left side may be used, but with caution regarding loose items in the sleep space. Wedges designed for this purpose were discussed as a safer alternative. Will monitor head shape at subsequent visits. 4. Nasolacrimal duct obstruction: Reassurance that this is common and can take months to resolve. Parents counseled on signs of infection to watch for (significant increase in amount of discharge, eye redness). Breast milk can be applied to the eye as a home remedy given its antibody content. Continue wiping with gauze. 5. Accessory nipple: Reassurance provided that this is a benign finding that will become more inconspicuous as the child grows. No intervention needed. 6. Ear cartilage variant: Benign cartilage variant, likely inherited from mother's ear anatomy. No intervention needed. 7. Gassiness: Reassurance that transient gassiness is part of normal newborn GI adjustment and not likely related to maternal dairy intake. Mother encouraged not to restrict her diet unless a persistent, reproducible pattern is identified with a specific food. Encouraged to continue drinking milk for calcium intake. 8. Breastfeeding: Mother reassured that stool pattern and feeding frequency are appropriate. Encouraged to transition from scheduled feeds to cue-based feeding, as milk supply is well established and baby is gaining weight appropriately. Baby does not appear hungry after feeds. If the baby goes beyond approximately 6 hours without feeding on a regular basis, that would warrant attention, but occasional longer stretches are acceptable. Mother counseled about the normalcy of postpartum weight loss in newborns and reassured about her feeding adequacy. Provider discussed monitoring for postpartum mood concerns — if worry about feeding becomes pervasive or interferes with sleep, further discussion warranted. Circumcision scheduled for the following day at the obstetrician's office. Parents advised to gently retract during diaper changes to promote healing of the circumcision site. ANTICIPATORY GUIDANCE Newborn skin desquamation (molting) is normal and will resolve on its own. Safe sleep practices discussed. Temperature regulation counseled — baby should not be taken outside in excessive heat as he cannot regulate his body temperature; a thin knit hat should be worn at home given typical indoor temperatures of 70-75°F to prevent heat loss through the head. Long-sleeved onesies appropriate for indoor wear. Mother encouraged to get outside independently for walks, eat foods she enjoys including simple carbohydrates to support caloric demands of breastfeeding, and prioritize rest. Discussed that breastfeeding caloric demands may exceed those of late pregnancy and that maternal hunger cues should be followed. Continue vitamin D supplementation. FOLLOW-UP Return at 2 months of age for well child visit and initiation of vaccines. ICD-10 CODES Z00.121 - Encounter for routine child health examination with abnormal findings P59.9 - Neonatal jaundice, unspecified CPT CODES 99391 - Preventive medicine, established patient, infant (age under 1 year) ───────────────────────────────────────── CODES: CPT 99391 | ICD-10 Z00.121, P59.9