Well-Child Check Clinic Note LOCATION: Outpatient, Hospital

Well-Child Check Clinic Note LOCATION: Outpatient, Hospital PATIENT: Bradley Wellingstone PHYSICIAN: Rolando Ortez, MD SUBJECTIVE: This is a 3-week-old former 32-week gestational male infant who was in RNICU from birth. He did have some mild respiratory difficulties, oxygen requirements that resolved without further sequelae. He was also there for sepsis and feeding difficulties as well as apnea. He was discharged home on caffeine citrate, home apnea monitoring. He did return 2 days ago to get his first dose of Synagis. He is here for general checkup otherwise. OBJECTIVE: He is on 24-calorie Enfamil and is taking that well without difficulty, taking almost 2 ounces at feeding; urinating and stool schedule is normal. No other complaints from his mother. ASSESSMENT: On exam, alert, in no distress, and afebrile. His weight is up to 2341 grams, which is up 150 grams. Fontanelle, eyes, ears, nose, and pharynx are clear. Neck is supple. Lungs are clear to auscultation. Heart is regular rate and rhythm without murmur. Abdomen benign. Extremities: Full range of motion. No hip abnormalities. Skin is without rash. Neurologic exam without defect. IMPRESSION: Thriving former 32-weeker. Now 3 weeks old. PLAN: Anticipatory guidance discussed. We talked about feeding issues, accident prevention, car seat use, sleeping position on the side or the back. We will see them back in 1 month for his next Synagis dose as well as a recheck. We will have him on caffeine citrate 10 mg/day along with home apnea monitoring with plans to stop the caffeine in 1 month. With any problems, they need to give us a call or come back in sooner for re-evaluation. CPT Code(s): ICD-10-CM Code(s):

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