Office Visit Note
Reason: Office Visit Narrative: SUBJECTIVE: Chief Complaint: Well-child check HPI: 3-month-old female presenting for routine well-child examination. Mother reports infant is doing well overall. Infant is exclusively breastfeeding and tolerating feeding well without difficulty. No concerns raised by family at this time. Development: Infant cooing and vocalizing, beginning to track objects visually and showing social smile. Demonstrating improved head control with ability to hold head steady when pulled to sit. Beginning to reach and grasp for objects brought to midline. Sleep: Age-appropriate sleep patterns without concerns reported. Nutrition: Exclusive breastfeeding, nursing well with good latch and milk transfer. Vitamin D supplementation provided daily. OBJECTIVE: Physical Examination: - General: Alert, interactive, responsive to voices and faces, content without distress, appropriate for age - HEENT: Anterior fontanelle soft and open, appropriate size. Eyes bright and reactive, following objects. Ears symmetric, canals patent. Nasal passages patent. Mouth and oropharynx clear. - Cardiovascular: Regular rate and rhythm. No murmur appreciated. Capillary refill brisk, peripheral pulses intact. - Respiratory: Clear to auscultation bilaterally, no retractions, no distress. Good air entry throughout. - Abdomen: Soft, nondistended, bowel sounds present. No organomegaly palpated. No masses appreciated. - Musculoskeletal: Full range of motion all extremities. Normal tone and strength for age. Hips stable on Ortolani and Barlow maneuvers. No clubfoot or other deformity. - Skin: **Flat vascular lesion over posterior scalp noted, unchanged from prior visit.** No other rashes, lesions, or concerning findings. Skin warm and well-perfused. - Neurologic: Age-appropriate reflexes present. Good grasp reflex. Normal developmental trajectory. ASSESSMENT: 1. Routine well-child check, 3 months of age (ICD-10: Z00.00) Infant growing and developing appropriately with normal physical examination. No acute or chronic illness identified. Stable benign vascular lesion noted on skin exam, consistent with capillary malformation, unchanged and requiring no intervention. PLAN: Continue exclusive breastfeeding; mother doing well with nursing. Continue vitamin D supplementation daily (appropriate for breastfed infant to ensure adequate vitamin D stores and prevent rickets). Anticipatory guidance reviewed: Discussed importance of tummy time daily for 2-3 minutes to support motor development and reduce positional plagiocephaly risk. Reviewed safe sleep practices including firm flat surface, back sleeping position, and avoiding pillows or blankets. Discussed expected developmental progress over next month (improved head control, cooing developing into babbling, increased visual tracking). Mother counseled that flat vascular lesion is benign and typically fades with time; no treatment indicated at this time. Return in 1-2 weeks for 4-month well-child check and routine vaccinations (DTaP, IPV, Pneumococcal, Rotavirus, Hepatitis B series). Parents instructed to call with any intervening concerns including fever, difficulty feeding, respiratory distress, or behavior changes. CPT: 99391 REFERENCES: 1. American Academy of Pediatrics. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th ed. 2017. 2. Hagan JF, et al. Recommendations for preventive pediatric health care. Pediatrics. 2017;139(4):e20170254. 3. Wagner CL, et al. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics. 2018;142(1):e20182087. ───────────────────────────────────────────────── CODES: CPT 99391 | ICD-10 Z00.00 [Routine normal findings assumed unless specified]