Office Visit Note
Narrative: CHIEF COMPLAINT Well child visit for 5-year-old HISTORY OF PRESENT ILLNESS Jack is a 5-year-old male presenting for a well child visit. He is preparing to start school at a new program ('rec'). Parents report that his eating habits fluctuate. Mother describes him as 'very sensitive' with behavioral patterns consistent with his developmental stage, including big emotions, occasional anger, and some immaturity. Parents note he is funny, especially at home, though this has not yet fully emerged at school. He has an older brother with 'big feelings and big energy,' which can influence the dynamic. Mother inquired about his asthma management plan and reports he has not really needed his asthma medications recently. No acute concerns were raised. REVIEW OF SYSTEMS No acute symptoms reported. No respiratory complaints. Denies recent need for asthma rescue medication per parent report. MEDICATIONS REVIEWED Asthma medications discussed; mother reports he has not really needed them recently. No changes made. No school action plan requested by the school. PHYSICAL EXAM Weight: 47.8 lbs. Height: 46.45 inches (3 feet 10.5 inches). Growth percentiles: 90th percentile for height, 75th-80th percentile for weight. General: Well-appearing, age-appropriate behavior. Anxious regarding vaccination but otherwise cooperative. ASSESSMENT 1. Well child visit, age 5 years - Growth tracking well with height at 90th percentile and weight at 75th-80th percentile. Developmentally appropriate behavior for age. 2. Age-appropriate behavioral concerns - Emotional sensitivity, occasional anger outbursts, and immature behaviors consistent with developmental stage. Parents counseled. 3. Asthma - Stable, not requiring recent use of medications per parent report. PLAN 1. Well child visit: Growth and development reviewed. Growth parameters are appropriate. MMR vaccine administered to the left arm today. Flumist (influenza vaccine) deferred until available. School forms provided. 2. Behavioral concerns: Counseled parents extensively on age-appropriate expectations for a 5-year-old. Discussed that significant 4-year-old behavior persists at this age, and that his language abilities may create unrealistic expectations for emotional regulation. Advised parents to avoid over-talking through behavioral episodes and to reduce the intensity of parenting interactions when feeling frustrated. Normalized emotional outbursts in the context of tiredness, hunger, and growth. 3. Asthma: Stable without recent need for medication. No school action plan needed per parent. Will continue current management and reassess as needed. ANTICIPATORY GUIDANCE Discussed age-appropriate developmental expectations for a 5-year-old boy, including emotional immaturity despite verbal abilities. Counseled on managing sibling dynamics with an older brother. Discussed school readiness. FOLLOW-UP Routine well child visit per schedule; return sooner if concerns arise regarding behavior or asthma symptoms. ICD-10 CODES Z00.129 - Encounter for routine child health examination without abnormal findings J45.20 - Mild intermittent asthma, uncomplicated CPT CODES 99393 - Preventive visit, established patient, age 1-4 years ───────────────────────────────────────── CODES: CPT 99393 | ICD-10 Z00.129, J45.20