Office Visit Note
Narrative: CHIEF COMPLAINT Well child visit with skin irritation, ear irritation, and history of recurrent strep HISTORY OF PRESENT ILLNESS Charlie presents for a well child visit. Mom reports he has been experiencing skin irritation and ear irritation, which she suspects may be related to his current soap (Pepette, a natural/organic product). She is interested in switching to a less irritating alternative. Mom also reports Charlie has had strep throat twice — once in November and once over the summer. She is concerned he may be prone to recurrent strep infections. She notes that during the summer episode, he was not around anyone known to have strep and was the only one in the group who became ill. Mom otherwise states she does not have many questions or concerns about Charlie. REVIEW OF SYSTEMS Skin: Positive for skin irritation. Ears: Positive for ear irritation. Constitutional: No concerns reported. Otherwise review of systems not specifically discussed. PHYSICAL EXAM Weight: 50.1 lbs. Height: 48.5 inches. General: Well-appearing, cooperative child. HEENT: Oral exam reveals mixed dentition with recent tooth loss; **possible crossbite noted on dental inspection**. Ears: Examined. **Skin irritation noted** (location not further specified). Skin: **Irritation noted**. Cardiovascular: Examined without noted abnormality. Respiratory: Examined without noted abnormality. Abdomen: Examined without noted abnormality. ASSESSMENT 1. Well child visit — growth parameters obtained, development appropriate for age with big kid teeth coming in and recent tooth loss. 2. Skin irritation — likely contact irritation from current organic soap product (Pepette); organic/natural products can contain allergens. 3. Ear irritation — suspected related to same soap product. 4. History of recurrent strep pharyngitis — two episodes (November and summer); does not yet meet criteria for recurrent strep. 5. Possible crossbite — noted on dental exam. PLAN 1. Well child visit: Growth parameters reviewed. Continue routine well child care. 2-3. Skin and ear irritation: Discussed that organic and natural products can contain allergens that irritate sensitive skin. Recommended switching to a gentle, unscented cleanser such as Cetaphil. Charlie and his siblings with sensitive skin will benefit from fragrance-free products. 4. Recurrent strep: Reassured mom that two episodes do not yet establish a pattern of recurrent strep. This upcoming winter and school year with increased germ exposure will be informative, as winter is peak strep season. Will monitor. 5. Possible crossbite: Noted on exam. Monitor as permanent teeth continue to erupt; may warrant dental or orthodontic evaluation. FOLLOW-UP Routine well child visit follow-up; return sooner if recurrent strep episodes or worsening skin/ear irritation. ICD-10 CODES Z00.121 - Encounter for routine child health exam with abnormal findings L30.9 - Dermatitis, unspecified (contact skin irritation) CPT CODES 99393 - Preventive visit, established patient, age 5-11 years ───────────────────────────────────────── CODES: CPT 99393 | ICD-10 Z00.121, L30.9