Date: 3/11/21

Age: 2 weeks old

Chief Complaint: “vomiting” x 3 days

History of Present Illness:

PB is a 2 week old female with no significant past medical history presenting to the office today with her parents c/o excessive vomiting and some constipation for the past 3 days. Mother exclusively nurses the baby, and states that the patient vomits every time she nurses, about 10 minutes after she finishes eating. She states that it began gradually, and has been getting worse over the past few days. She describes the vomit as “shooting out” and the consistency of regular spit up. She states the baby has also not had a bowel movement over the past 2 days, and admits that she has been more irritable and lethargic than usual. She did not give her any medication, just continued nursing. Denies loss of appetite/ abnormal eating patterns, fever, rash, diarrhea, cough, congestion, recent travel, or sick contacts.

Past Medical History: No significant PMHX.

Immunizations – All vaccinations up to date.

Past Surgical History: Denies previous surgeries or blood transfusions

Medications: None

Allergies: none

Family History:

Mother – 24, alive and well

Father – 25, alive and well

Social History:

Baby was recently born, natural birth, no complications. Mother is currently at home with the baby, father works as an accountant

Habits – Mother denies any smoking in the household.

Travel – Mother denies any recent travel.

Review of Systems:

General – Admits to generalized fatigue/ lethargy, irritability, and lack of adequate weight gain. Denies recent loss of appetite, fever and chills, generalized weakness, or night sweats.

Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, discolorations,

pigmentations, moles/rashes, pruritus or changes in hair distribution.

Head – Denies head trauma.

Eyes – Denies itching, other visual disturbances

Ears – Denies any changes in hearing.

Nose/sinuses –Denies nasal discharge, obstruction, or nose bleeds.

Mouth/throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers.

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion

Pulmonary system –Denies cough, wheezing, difficulty breathing, coughing up blood, blue coloration.

Cardiovascular system – Denies syncope/loss of consciousness, palpitations, irregular heartbeat, or known heart murmur.

Gastrointestinal system – Admits to frequent vomiting and constipation. Denies difficulty swallowing, diarrhea, jaundice, or blood in stool.

Genitourinary system – Admits is having fewer wet diapers.

Nervous – Denies seizures, headache, loss of consciousness, sensory disturbances, imbalance, loss of strength change in cognition / mental status / memory, or weakness.

Musculoskeletal system – Denies muscle/joint pain, deformity or swelling, redness or arthritis.

Peripheral vascular system – Denies swelling of lower legs or hands, or color changes.

Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions.

Endocrine system – Denies increased drinking, eating, or urination, heat or cold intolerance, excessive sweating.

Physical Exam:

General: Well-appearing, well-nourished, alert and oriented

Vital Signs:

R: 40 breaths/min, unlabored P: 130 beats/min, regular

T: 98.5 degrees F (tympanic)   O2 Sat: 100% on room air

Height: 19 inches Weight: 8 lbs 4 oz. BMI 16

Skin: Warm and moist, normal turgor.

Hair: Average quantity, even distribution, smooth texture. No signs of seborrhea, lice, or nits.

Nails: No clubbing, capillary refill < 2 seconds throughout.

Head: Normocephalic, atraumatic, nontender to palpation.

Eyes: Symmetrical OU, No evidence of strabismus, exophthalmos, or ptosis. Sclera is white, conjunctiva pink, and clear.

Ears: Symmetrical and normal size. No evidence of lesions, masses, or trauma to external ears. No discharge or foreign bodies in external auditory canals AU. Tympanic membranes pearly gray with cone of light well seen.

Nose: Nasal mucosa moist, no discharge. Symmetrical, no obvious masses, lesions, deformities, trauma. Septum midline without lesions, deformities, injection, or perforation. No evidence of foreign bodies.

Mouth and Pharynx: Pharynx well hydrated, no injection, exudate, masses, or lesions noted. Uvula pink, no erythema, lesions, Tonsils present, 1+. Lips pink and moist without cyanosis or lesions. Non-tender to palpation. Palate pink and well-hydrated, without lesions, masses, scars. Palate rises symmetrically. Gingivae pink and moist. Tongue pink, well-papillated

Lungs: Clear to auscultation bilaterally, no audible wheezing, rhonchi, or stridor. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus intact throughout.

Heart: Normal heart rate. S1 and S2 noted. No murmurs, S3, S4, splitting of heart sounds, friction rubs or extra sounds.

Abdomen: Distended, hard and tender to palpation, bowel sounds hypoactive in all 4 quadrants. Symmetrical, no scars, no pulsations or bruits noted, tympanic throughout, no guarding or rebound notes. No hepatosplenomegaly to palpation, no CVA tenderness appreciated.

Extremities: No evidence of clubbing, cyanosis or edema. DP and TP pulses 2+ B/L and equal.

Assessment:

TB is a 2 week old female with no significant pmhx who presents to the office today with both parents complaining of vomiting and constipation x3 days.

DDX:

1. Pyloric Stenosis- patient has projectile vomiting immediately after she eats. She is also lethargic, constipated, and not gaining weight properly.
2. Constipation- patient has not had a bowel movement for 2 days, her stomach is extremely distended, and bowel sounds are decreased. Increased buildup due to constipation could be leading to the vomiting.
3. Viral Gastroenteritis- patient is vomiting and constipated, so could be viral. However, no sick contacts at home.
4. GERD-patient is vomiting frequently, irritable, and having poor weight gain. However, patient is not coughing, wheezing or having difficulty breathing.
5. Hirschsprung’s Disease- is constipated and vomiting with abdominal distention. However, did pass meconium and was having bowel movements after birth.
6. Hereditary Metabolic Disorder (like PKU, but symptoms would usually come on later)

Plan:

1. Constipation, abdominal distention- use glycerin suppository, as needed. Return if ineffective.
2. Projectile Vomiting, Irritability, abdominal distention, poor weight gain-send for stat ultrasound, follow up within 24-48 hours