Emergency Room Report

CHIEF COMPLAINT:
Colic.

 HISTORY OF PRESENT ILLNESS:
This 6-week-old enters with colicky pain and increasing flatus and crampy abdominal pain that she gets mostly at night. She is not constipated. She has had no blood in her stool and normal urine and normal intake and no nausea or vomiting. She has not had any fever. 

PAST MEDICAL HISTORY:
Other than the above, symptoms is negative. 

PAST SURGICAL HISTORY:
Negative.

SOCIAL HISTORY:
Negative. Both parents are present and appropriately concerned.

FAMILY HISTORY:
Negative.

REVIEW OF SYSTEMS:
The complete review of systems is essentially negative except for colicky abdominal pain and increased flatus. The patient is on formula with iron and does not use a gas decreasing bottle system. Has been on Gaviscon but has gotten only one dose a night apparently. The rest of the review of systems is negative.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.9. Pulse 130. Respirations 52. Pulse oximetry is 96% on room air.
GENERAL APPEARANCE: She is alert and is moving all extremities.
HEENT: The pharynx is wet. The tympanic membranes are normal. The fontanel is soft and ballotable.
NECK: Supple. There is no induration of the throat and there is no adenopathy.
LUNGS: Clear. There is no dyspnea.
HEART: Shows a regular rhythm without murmurs.
ABDOMEN: Somewhat distended. She had some flatus several times, I might add, and then it diminishes. It is totally nontender. She has good tone.
NEUROLOGIC: Intact for age including a positive Moro.
SKIN: She has no skin lesions, icterus, or jaundice, and the pulses are 2+ and equal.

DATABASE:
X-rays: Upright abdominal and chest combination is normal except for gas in the bowel, which shows no obstruction.

DISCUSSION:
I think this is colic. I have suggested the following: (1) To change to formula without iron. (2) To use soy based formula. (3) To increase the Gaviscon to 3 drops q.i.d. at least. (4) They should follow up with their own doctor.

CLINICAL IMPRESSION:
Colic.

PLAN:
Gaviscon, changing the formula, no iron, and see their doctor in 1-7 days.

CONDITION ON DISCHARGE:
Good


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