Office Visit Note
Narrative: CHIEF COMPLAINT Well child visit with concerns about lazy/crossed right eye and pacifier use HISTORY OF PRESENT ILLNESS Bo presents for a well child visit. His mother reports she has noticed a lazy or crossed eye, which she believes is the right eye. She notes that he sleeps with a bear that he holds up to one side of his face and appears to try to look around it. The clinician explained that this is likely due to asymmetry in eye strength rather than the bear causing the issue, and that Bo is responding to a pre-existing condition. Father wears glasses. Bo has not yet been evaluated by an ophthalmologist. Mother also inquires about pacifier use. Bo is reportedly fully potty trained and starting school soon. REVIEW OF SYSTEMS Eyes: Parent reports intermittent crossing/deviation of the right eye; observed closing one eye to refocus. ENT: History of ear drops (completed). Denies other acute concerns. MEDICATIONS REVIEWED Ear drops (recently completed course discussed). PHYSICAL EXAM Weight: 32.2 lbs. Height: 39 inches (3 feet 3 inches). General: Well-appearing, cooperative child. Eyes: **Right eye with intermittent esotropia/crossing noted on exam; observed closing one eye to refocus.** ENT: Ears examined post-ear drop treatment. Oropharynx examined — **tonsillar hypertrophy noted bilaterally.** Dentition visualized. Abdomen: Examined, no abnormalities noted. Genitourinary: Male, circumcised (or uncircumcised — not specified), normal external genitalia on inspection. Musculoskeletal/Neurologic: Walks on tiptoes and heels appropriately. Able to stand on one foot bilaterally with good balance. Gait normal. ASSESSMENT 1. Well child visit — age-appropriate growth and development. 2. Strabismus, right eye — parent reports intermittent lazy/crossed appearance of the right eye, confirmed on exam with intermittent deviation and compensatory eye closing. Family history of refractive error (father wears glasses). Not yet evaluated by ophthalmology. 3. Tonsillar hypertrophy — noted incidentally on exam, asymptomatic. 4. Pacifier use — ongoing, discussed in context of developmental readiness and dental implications. 5. Potty training — fully potty trained per parent report. PLAN 1. Well child visit: Growth and development are age-appropriate. Developmental milestones met including balance, gait, and single-leg stance. Vaccines administered per schedule. 2. Strabismus, right eye: Referral to pediatric ophthalmology recommended. Northwest Eye Care discussed as an option convenient to the family. The clinician counseled that early evaluation is important to prevent worsening, as the stronger eye may compensate further while the weaker eye declines. Treatment options were discussed including corrective glasses to blur the stronger eye, patching of the stronger eye (potentially 16–18 hours per day), and in more advanced cases, surgical correction. Mother understands the importance of prompt evaluation before school starts. 3. Tonsillar hypertrophy: Incidental finding. No intervention at this time. Monitor for symptoms of obstruction or sleep-disordered breathing. 4. Pacifier use: Clinician advised focusing on one behavioral milestone at a time — either pacifier weaning or another transition — rather than addressing multiple changes simultaneously, given that Bo is starting school. ANTICIPATORY GUIDANCE Discussion regarding school readiness. Counseled on importance of addressing one major behavioral change at a time (pacifier weaning vs. other transitions). Safety and age-appropriate anticipatory guidance provided. FOLLOW-UP Follow up with pediatric ophthalmology (Northwest Eye Care recommended) for dilated refracted eye exam and visual acuity assessment. Routine well child visit per schedule. ICD-10 CODES Z00.121 - Encounter for routine child health examination with abnormal findings H50.011 - Esotropia, unspecified, right eye CPT CODES 99392 - Preventive visit, established patient, age 1-4 years ───────────────────────────────────────── CODES: CPT 99392 | ICD-10 Z00.121, H50.011