Baby Consult -- P2

Chief Complaint

Baby Consult -- P2

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Issues 1) Poor weight gain 2) Ankyloglossia - status post tongue tie release 3) ?Increased right handed fistedness I had the pleasure of reviewing [age] Day old [name] in the office on [date]. As you know, [pronoun] has been followed for the above issues. I wanted to update you on our latest visit. Since last seen, [name] has had an anterior tongue release completed by a pediatric dentist. [pronoun] has had no hospitalizations and no ED visits. After [pronoun] tongue-tie release, there were no obvious changes in [pronoun] breastfeeding. [pronoun] continues to predominantly bottle feeding. [pronoun] mother wonders if [pronoun] is having less reflux. Currently, [name] breastfeeds about once per day for [duration]. [pronoun] will take [number] bottles per day of mostly EBM and will take [volume] over [duration]. [name] bottle feeds every [duration] and up to [duration] overnight. [pronoun] has spit up rarely, which is non-bloody and non-bilious. [pronoun] is typically unbothered by the spit up and does not have significant back arching or discomfort while lying flat. [pronoun] is kept upright after a feed. [pronoun] has [number] BMs per day that are yellow/gold. [pronoun] does not have pale stools or stools with blood. [pronoun] has [number] wet diapers per day. [name]'s parents wonder if [pronoun] has a flat spot on [pronoun] head. [pronoun] does not have an obvious gaze preference. [pronoun] mother has not noticed any changes to [pronoun] lymph node. [pronoun] occasionally has a cough but no fevers or illnesses. **Development:** - Gross Motor: tummy time, can roll tummy to back, can push self [pronoun] up - Fine Motor: fisted about 50% of the time with right hand tending to be more fisted than the left. - Social: eye contact, smiling, some early giggles - Speech+Language: cooing There have been no developmental regressions. There have been no concerns with growth or development. [pronoun] has met developmental milestones on time. **Medications**: [medication], **Allergies**: nkda **Immunizations**: up to date **Physical examination:** Weight (kg): [weight] Height (cm): [height] Head Circ. (cm): [head_circumference] BMI: [bmi] Weight-age percentile: [percentile] Height-age percentile: [percentile] Head Circumference-age percentile: [percentile] Weight-Height percentile: [percentile] HEENT: moist mucus membranes, normal palate, normal red reflexes, normal head shape Resp: no increased work of breathing, clear to auscultation CVS: normal heart sounds, no murmurs, good femoral pulses, normal capillary refill Abdo: soft and non-tender, no hepatosplenomegaly, normal bowel sounds Neuro: good tone, normal power and reflexes Skin: no rash or jaundice MSK: hips normal **Impression and Plan** In summary, [name] is now [age] Day old. [pronoun] is tracking along [pronoun] growth curves and is meeting [pronoun] developmental milestones. Today we reviewed the following: 1. Feeding and weight gain - [name] has gained on average [weight_gain] per day over the last three weeks. I have suggested continuing to follow [pronoun] feeding cues to support [pronoun] weight gain. 2. Development - I will refer [name] to the [program] to support [pronoun] development given that [pronoun] mother wonders if [pronoun] right hand is more fisted than [pronoun] left. [pronoun] other domains of development appear on track. If [pronoun] falls behind at [pronoun] next check, [pronoun] may benefit from a referral to private physiotherapy as well. I will plan to see [name] again in [duration] or else sooner if there are concerns. Thank you again for involving me in [name]'s care. Please do not hesitate to contact me with any questions or concerns.