2 month check-up

Subjective:
Introduction:
Emily seen with mother.

Concerns:
The mother expresses concern regarding Emily's feeding adequacy and recent lack of weight gain.

Immunization summary:
No immunization history or status provided.

Family history:
No significant family medical history provided.

Lifestyle/Social history:
No relevant lifestyle or social history provided.

Nutrition:
Emily is exclusively breastfed via direct nursing for the past month. Previously, expressed breast milk was occasionally provided by bottle.

Vitamin D:
No information available.

Feeding problems:
There is concern about insufficient intake as Emily sometimes falls asleep during feeds and does not always display clear satiety cues. Emily does not cry to indicate hunger. Emily does not vomit forcefully or seem uncomfortable.

Elimination:
Stools: No information available. Urine output: No information available.

Development:
No developmental concerns reported.

Sleep:
No information available.

Parental coping:
No concerns regarding parental coping were expressed.

Birth history:
No birth history provided.

Objective:
Physical Examination:
General: Appears well, alert, in no distress.
Jaundice: No.
Head: No information available.
EENT: No information available.
Red reflexes: No information available.
Plagiocephaly: No information available.
Torticollis: No information available.
Heart sounds: No information available.
Chest: No information available.
Abdomen: No information available.
Hips: No information available.
Genitalia: No information available.
Tone: No information available.
Diaper rash: No information available.
Skin: No information available.
Spine: No information available.

Assessment and Plan:
Assessment:
Inadequate weight gain with concern for insufficient breast milk intake.

Plan:
The mother is advised to pump and bottle-feed Emily for one week to monitor intake, ensuring a daily intake of 700–800 mL with feedings every 3–4 hours during the day. Supplementation with formula or stored milk is recommended if intake is less than 700 mL. The mother is instructed to track at least 5 wet diapers per day and monitor stool frequency. Emily is to return for a weight check in one week, with a target weight gain of at least 200 grams. Daily intake amounts should be recorded. No immunizations were administered during this visit. Anticipatory guidance, advice, and education were provided following the Rourke Baby Record guide. The Caring for Kids website was recommended for additional resources.