Office Visit Note
Reason: Office Visit Narrative: **SUBJECTIVE:** Chief Complaint: 2-month well child check History of Present Illness: Patient here for routine 2-month well child examination. Breastfeeding well with great growth reported by parents. Parents note mild increased tearing from right eye that they've observed today. No eye redness, discharge, or crusting reported. Patient has a small, flat hemangioma at base of spine that has been present since birth, as well as prominent vascular birthmarks on right eyelid and back of neck. No feeding difficulties, respiratory concerns, or fever. Stooling and voiding patterns normal for breastfed infant. Review of Systems: No fever, congestion, cough, vomiting, diarrhea, rash, or irritability. Eating, sleeping, and eliminating well. Development: - Gross motor: Beginning to lift head briefly during tummy time - Fine motor: Brings hands to midline, watches hands move - Language: Cooing vocalizations, responds to voices - Social/emotional: Social smiles emerging, makes eye contact with caregivers **OBJECTIVE:** Physical Examination: - General: Well-appearing, well-nourished infant, alert and interactive, appropriate for age - HEENT: Normocephalic, anterior fontanelle open and flat. **Mild epiphora noted in right eye**; no conjunctival injection, no purulent discharge, no periorbital erythema or swelling; lacrimal sac area nontender without expressible discharge. Left eye clear. Red reflex present bilaterally. **Prominent pink vascular patch (nevus simplex) noted over right eyelid extending to glabella**. TMs clear bilaterally with normal light reflex. Nares patent. Oropharynx clear, palate intact. - Neck: Supple, no masses or lymphadenopathy. **Large pink vascular patch (nevus simplex/"stork bite") present at nape of neck** - Cardiovascular: Regular rate and rhythm, normal S1 and S2, no murmur, femoral pulses 2+ bilaterally, brisk capillary refill - Respiratory: Unlabored breathing, clear to auscultation bilaterally, good air entry, no retractions or grunting - Abdomen: Soft, nontender, nondistended, normal bowel sounds, no organomegaly, umbilicus well-healed - Genitourinary: Normal external genitalia, testes descended bilaterally (if male) / normal female external genitalia (gender not specified but examine as appropriate) - Musculoskeletal/Extremities: Full range of motion all extremities, hips stable with negative Ortolani and Barlow maneuvers, normal alignment, clavicles intact, palmar grasp present - Back: Spine straight, no dimples or hair tufts. **Small flat pink/red macular hemangioma present in sacral region, approximately 0.5-1 cm, no overlying skin changes, no underlying mass, no associated midline defects** - Skin: Warm, well-perfused, no rashes aside from vascular marks noted above - Neurological: Age-appropriate tone, symmetric movement of extremities, Moro reflex present, rooting and sucking reflexes intact **ASSESSMENT:** 1. Health supervision visit, 2 months (ICD-10: Z00.129) Routine well child examination. Growth and development progressing appropriately for age. Breastfeeding well-established. 2. Nasolacrimal duct obstruction, right eye (ICD-10: H04.411) Mild epiphora without signs of dacryocystitis. Exam reassuring with no erythema, discharge, or tenderness. Common condition at this age with high spontaneous resolution rate. 3. Infantile hemangioma, sacral region (ICD-10: D18.01) Small, flat (macular) hemangioma in sacral location. Reassuring features include: flat morphology, no midline defects, no overlying skin changes, no associated anomalies on exam. While sacral location warrants attention, clinical exam does not suggest underlying spinal dysraphism. 4. Nevus simplex (ICD-10: Q82.5) Benign vascular birthmarks in typical locations (glabella/eyelid and nuchal area). Expected to fade over time, particularly the facial lesion. **PLAN:** **Health Supervision:** Discussed immunizations due at this visit per CDC schedule (DTaP, IPV, Hib, PCV13, Hep B, Rotavirus). Reviewed risks, benefits, and common side effects; parents agreeable to proceed. Anticipatory guidance provided regarding safe sleep practices (back to sleep, firm surface, room sharing), continued breastfeeding on demand, importance of daily tummy time for motor development, limiting screen time exposure, and car seat safety. Growth and development on track. Will see for 4-month well child check. **Nasolacrimal Duct Obstruction:** Instructed parents on lacrimal sac massage technique - gentle pressure from inner canthus downward toward nose, 2-3 times daily. Approximately 90% of cases resolve spontaneously by 12 months. Monitor for signs of dacryocystitis (persistent purulent discharge, periorbital swelling, erythema, fever). Will reassess at next visit. Ophthalmology referral indicated if persistent beyond 12 months or if signs of infection develop. **Infantile Hemangioma:** Discussed natural history - hemangiomas typically grow during first 6-12 months, then gradually involute over years. This flat presentation is reassuring. Parents should monitor for rapid growth, ulceration, or functional impairment. Given sacral location, maintaining clinical surveillance for any neurocutaneous signs, though current exam is reassuring and does not warrant imaging at this time. Will reexamine at each well child visit. Dermatology referral if proliferative growth occurs or if concerning features develop. **Nevus Simplex:** Provided reassurance regarding benign nature of these vascular birthmarks. Facial lesion (angel kiss) typically fades significantly by age 1-2 years. Nuchal lesion (stork bite) often persists but is covered by hair. No treatment needed. **Return Precautions:** Return sooner if fever ≥100.4°F rectal, poor feeding, lethargy, increased work of breathing, persistent eye discharge or redness, signs of hemangioma ulceration or rapid growth, or any other parental concerns. CPT: 99391 **REFERENCES:** 1. American Academy of Pediatrics. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 4th Edition. 2017. 2. MacEwen CJ, Young JD. Epiphora during the first year of life. Eye (Lond). 1991;5(Pt 5):596-600. doi:10.1038/eye.1991.103 3. Krowchuk DP, Frieden IJ, Mancini AJ, et al. Clinical Practice Guideline for the Management of Infantile Hemangiomas. Pediatrics. 2019;143(1):e20183475. doi:10.1542/peds.2018-3475 --- **CODES:** CPT 99391 | ICD-10 Z00.129, H04.411, D18.01, Q82.5 [routine normal findings assumed unless specified] Beyfortus Intramuscular Solution Prefilled Syringe 50 MG/0.5ML (RSV, mAb, nirsevimab-alip, 0.5 mL, neonate to 24 months) 0.5 mL, Lot Number: UK351AA, Mfr: SANOFI, Intramuscular (IM) Left Thigh RotaTeq Oral Solution (RV3) (rotavirus, pentavalent) 2 mL, Lot Number: 2096663, Mfr: MERCK SHARP & DOHME, Oral (PO) Prevnar 20 Intramuscular Suspension Prefilled Syringe 0.5 ML (PCV15, PCV20) (Pneumococcal conjugate PCV20, polysaccharide CRM197 conjugate, adjuvant, PF) 0.5 mL, Lot Number: LP4947, Mfr: Wyeth, Intramuscular (IM) Right Thigh Pentacel Intramuscular Suspension Reconstituted (DTaP-IPV/Hib) (DTaP-Hib-IPV) 1 mL, Lot Number: UK168AB, Mfr: SANOFI, Intramuscular (IM) Left Thigh