Office Visit Note
Narrative: CHIEF COMPLAINT Well child visit with chronic mouth breathing, nasal obstruction since infancy, nasally speech, and tongue-tie noted by dentist; due for vaccines HISTORY OF PRESENT ILLNESS Griffin is a 2-year-old male presenting for a well child visit. Mom reports chronic mouth breathing and nasal obstruction that has been present since infancy. She was previously told his nasal passages were narrower and that he would outgrow the issue, but symptoms have persisted. His speech is notably nasally — he cannot say "mama" and instead says "baba." When eating, he is unable to close his mouth and chews with his mouth open. As an infant, his feeding with bottles appeared labored enough that family members questioned whether he was choking, though this was described as his baseline. Mom also reports he still uses a pacifier at nighttime and they are actively weaning. She has noticed his teeth are beginning to shift from pacifier use. Sleep is described as good — he sleeps well and does not appear unrested. Mom additionally reports that his dentist recently identified a tongue-tie. Mom notes Griffin is starting preschool this fall. REVIEW OF SYSTEMS Pertinent positives: chronic mouth breathing, nasal congestion/obstruction since infancy, nasally speech, open-mouth chewing, tongue-tie identified by dentist, dental shifting from pacifier use. Pertinent negatives: no sleep disturbance, no daytime fatigue or appearing unrested. PHYSICAL EXAM Weight: 32.2 lbs. Height: approximately 3 feet. General: Active toddler, initially hesitant with exam, warms up appropriately. Cooperative with some coaxing. HEENT: Attempted examination of nose and oropharynx — patient was resistant to full nasal and oral exam. **Mouth breathing observed.** Tongue-tie evaluation limited by cooperation. Behavior/Development: Bright, interactive, verbal (though nasally), follows directions with redirection, engages with examiner and family appropriately. ASSESSMENT 1. Chronic nasal obstruction with mouth breathing since infancy — persistent despite prior reassurance that he would outgrow narrow nasal passages. Speech is affected (nasally quality, substitution of consonants). Possible enlarged adenoids versus structural narrowing. Warrants ENT evaluation. 2. Tongue-tie — noted by dentist, not fully evaluated today due to limited cooperation with oral exam. 3. Pacifier use — nighttime use with active weaning in progress; dental shifting noted by parent. 4. Well child visit, age 2 years — growth and development appear appropriate. Immunizations addressed. 5. Immunizations — due for varicella (never received), DTaP (4th dose), Prevnar (4th dose, nearing age-out). Hepatitis A series not yet started. PLAN 1. Nasal obstruction/mouth breathing: Referral to ENT for evaluation of chronic nasal obstruction and possible adenoid hypertrophy. Provider will send family a specific ENT recommendation. ENT evaluation is informational and does not obligate surgical intervention. Discussed possible etiologies including narrowing of nasal passages, enlarged adenoids, and enlarged tonsils. Discussed that intervention would depend on degree of impact on sleep, speech, and development. 2. Tongue-tie: Noted per dentist report. Will defer further evaluation to ENT visit given planned referral. 3. Pacifier weaning: Encouraged continued weaning given observed dental shifting. Discussed that pacifier use is not ideal for dental development. 4. Immunizations: After discussion of vaccine prioritization with mom, who prefers spacing vaccines, varicella vaccine was administered today (left leg). Plan to return for DTaP (separated from combination vaccine since he will age out of Hib) and Prevnar before he ages out. Hepatitis A series discussed but deferred. Mom prefers minimal approach with return visits for remaining vaccines. 5. Well child care: Growth parameters reviewed — weight and height appropriate. Development appears on track — bright, verbal, interactive. Follow-up at 30 months for well child check and additional vaccine administration. ANTICIPATORY GUIDANCE Discussed that bright, intelligent toddlers can be more challenging to parent. Encouraged continued engagement with developmental activities as he prepares for preschool this fall. FOLLOW-UP Return at 30 months for well child visit and additional vaccines (DTaP, Prevnar). ENT referral to be scheduled over the summer. ICD-10 CODES Z00.121 - Encounter for routine child health examination with abnormal findings J34.89 - Other specified disorders of nose and nasal sinuses (chronic nasal obstruction) CPT CODES 99392 - Preventive visit, established patient, age 1-4 years ───────────────────────────────────────── CODES: CPT 99392 | ICD-10 Z00.121, J34.89