Office Visit Note
Reason: Office Visit Narrative: **SUBJECTIVE:** Chief Complaint: 11-year-old well child check HPI: 11-year-old male presents for routine well child examination. Reports not feeling well for the past 2 days with mild sore throat. Denies fever. No other upper respiratory symptoms. Currently managed on guanfacine XR 1 mg twice daily for ADHD. Performing well academically and socially at school. Parents report continued large behavioral outbursts at home despite medication. Otherwise healthy with no dietary or sleep concerns reported. Development: Demonstrates age-appropriate academic performance in 6th grade. Maintains positive peer relationships and engages in social activities. Shows increasing independence with self-care and decision-making. Exhibits abstract reasoning abilities appropriate for age. PMH: ADHD on medication management --- **OBJECTIVE:** Physical Examination: - General: Alert, cooperative, well-appearing, in no acute distress - HEENT: **Oropharynx with erythematous posterior pharynx. Positive anterior cervical lymphadenopathy noted.** TMs clear bilaterally. Nares patent. - Neck: Supple, lymphadenopathy as noted above - Cardiovascular: Regular rate and rhythm, normal S1/S2, no murmur - Respiratory: Clear to auscultation bilaterally, unlabored breathing - Abdomen: Soft, non-tender, non-distended, normal bowel sounds - Musculoskeletal: Normal gait, full range of motion, no deformities - Neurological: Alert and oriented, age-appropriate cognition and affect - Skin: No rashes or lesions noted - Genitourinary: **Tanner stage 3-4** Rapid Strep Test: **Positive** --- **ASSESSMENT:** 1. Encounter for routine child health examination with abnormal findings (ICD-10: Z00.121) Growth and development appropriate for age. Puberty progressing normally. 2. Streptococcal pharyngitis (ICD-10: J02.0) Positive rapid strep test with clinical findings consistent with streptococcal pharyngitis. 3. Attention-deficit/hyperactivity disorder, combined type (ICD-10: F90.2) Currently managed on guanfacine with good school functioning but persistent behavioral dysregulation at home. Will optimize medication dosing. --- **PLAN:** Well child check: Immunizations due - patient scheduled to return this week for Tdap, HPV, and MenACWY vaccines. Discussed puberty changes, social media safety, and importance of physical activity. Encouraged continued academic engagement. Streptococcal pharyngitis: Prescribed penicillin VK 500 mg three times daily for 10 days. Discussed importance of completing full antibiotic course. May return to school 24 hours after starting antibiotics if feeling well and afebrile. Avoid sharing drinks or utensils. Return if fever develops, symptoms worsen, or difficulty swallowing occurs. ADHD: Increasing guanfacine XR to 1.5 mg twice daily to address persistent behavioral outbursts at home. Discussed behavioral strategies including consistent routines, clear expectations, and positive reinforcement. Will reassess response at follow-up. Monitor for sedation or blood pressure changes with increased dose. Return for scheduled vaccinations this week. Return sooner for worsening sore throat, new symptoms, or concerns about medication side effects. Routine follow-up in 1 year for 12-year well child check. **CPT:** 99383 --- **REFERENCES:** 1. Shulman ST, et al. Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2012;55(10):1279-1282. 2. American Academy of Pediatrics. Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th edition. 2024. 3. Wolraich ML, et al. Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics. 2019;144(4):e20192528. --- **CODES:** CPT 99383 | ICD-10 Z00.121, J02.0, F90.2 [routine normal findings assumed unless specified]