Cleft Palate New Visit

Subjective:
Chief Complaint:
Infant feeding concerns and weight gain issues

Current Concerns:
Ella's mother expresses concern regarding Ella's feeding and weight gain. Ella is exclusively breastfed, and her mother is unsure of the volume Ella consumes during feeds, as Ella sometimes falls asleep while nursing and it is difficult to determine satiety. Ella has not gained much weight lately, and her weight has plateaued since three months of age. Additionally, Ella sometimes goes 5–6 hours between feeds without crying.

Medical History:
- Pregnancy & Birth History: No significant findings.
- Cleft Lip/Palate History: No cleft lip or palate history provided.
- Other Medical History: No other medical history provided.
- Medications: None.
- Allergies: No Known Allergies.
- Immunizations: No information available.

School/Education, Services & Community Supports:
- Grade Level: Not applicable.
- IEP/Designation: Not applicable.
- Support Services: Not applicable.
- Community Supports: Not applicable.
- Health Care: Ella is followed by her primary care provider.

Development Review:
No specific developmental observations were documented during the visit.

Review of Systems:
- Vision: No concerns reported.
- Hearing: No concerns reported.
- Swallowing/oromotor: No concerns reported.
- Nutrition: Ella is exclusively breastfed. Ella does not always show strong hunger cues. No forceful vomiting or discomfort reported.
- Elimination: Ella's mother is instructed to monitor for at least five wet diapers per day and to track stool frequency.
- Sleep: No concerns reported.
- Genetics: No information available.

Social History:
Ella lives with her mother, Grace. No additional social factors impacting Ella were reported.

Family History:
No relevant family medical history or genetic conditions were reported.

ID:
Ella was seen in the Cleft Palate Multidisciplinary Clinic on 2026-02-04, accompanied by her mother, Grace. This was Ella's first visit with the Multidisciplinary Cleft Palate clinic.

Patient Demographics:
Ella is an infant who lives with her mother, Grace. No further demographic details were provided.

Objective:
Physical Exam:
- Weight Measured: 5.3 kilograms (date not specified).
- Weight Percentile: No information available.
- Height/Length Measured: No information available.
- Height Percentile: No information available.
- Head Circumference: No information available.
- Systolic Blood Pressure: No information available.
- Diastolic Blood Pressure: No information available.

- General: No abnormal findings reported.
- HEENT: No abnormal findings reported.
- CV: No abnormal findings reported.
- Resp: No abnormal findings reported.
- Abdomen: No abnormal findings reported.
- Neuro: No abnormal findings reported.
- MSK: No abnormal findings reported.
- Derm: No abnormal findings reported.

Developmental Observations:
No specific developmental observations were documented during the visit.

Assessment:
Impression:
Ella is an infant with a history of appropriate weight gain until two months of age, followed by a plateau in weight from three to four months. She is exclusively breastfed, but her intake is uncertain. There are concerns regarding insufficient feeding volume and infrequent hunger cues. No acute medical or developmental concerns were identified during this visit.

Plan:
Recommendations:
- Mother to pump and bottle-feed Ella for one week to accurately measure daily intake.
- Target intake is at least 700 to 800 milliliters per day, with approximately 120 milliliters per feed if feeding six times daily.
- If intake is less than 700 milliliters per day, supplement with formula or stored breast milk.
- Feed Ella every three to four hours during the day, regardless of hunger cues.
- Monitor for at least five wet diapers per day and track stool frequency.
- Return for a weight check in one week, aiming for a weight gain of at least 200 grams.
- Record daily intake volumes for review at the next visit.

Consent:
Verbal consent was obtained from Ella's mother for the use of AI scribe during the visit, including an explanation of its purpose, benefits, limitations, and associated privacy and security risks.