Annual Physical Exam Visit Note
Reason: Annual Physical Exam, Well check Narrative: Subjective Chief Complaint: 7-year well child check. ROS (lean): No fever, cough, stridor, sore throat, or ear pain. No hearing or vision concerns reported. Normal appetite, energy, sleep, stooling/voiding per parent. No school or behavior concerns volunteered. HPI: Ex-premie (per parent, born ~10 days early). Past history notable for recurrent croup—family keeps dexamethasone at home for episodes; typically well between illnesses. Recurrent AOM—s/p tympanostomy tubes. Parent notes he has “always been smaller.” Today found to have an extruded right PE tube in canal; removed in clinic without issue. Child otherwise healthy; uncircumcised. Development (per parent/teacher): • Gross motor: Rides bike/active play; good balance. • Fine motor: Writes legibly; draws with detail/uses scissors. • Language: Full sentences; reading at grade level. • Social/emotional: Has friends; follows classroom rules/cooperates. PMHx: Recurrent croup; recurrent AOM s/p PE tubes. Meds: PRN dexamethasone on hand for croup [dose per home plan]. Allergies: [not documented]. Immunizations: [record not reviewed today]. Family/Social: Lives with family; school grade [__]; denies smoke exposure [per parent]. Objective Vitals: [not documented]. Physical Exam General: Alert, playful, well-appearing; small body habitus but proportionate. HEENT: PERRL, EOMI; conjunctivae clear. External ears normal. Right ear: extruded tympanostomy tube removed today with alligator forceps; canal clear post-removal; TM intact, no effusion/erythema. Left TM clear, landmarks visible. Nares clear. Oropharynx moist, no tonsillar hypertrophy or exudate. Neck: Supple, no LAD. Cardiac: RRR, no murmurs. Resp: Clear to auscultation, no wheeze/stridor; good air entry. Abd: Soft, nontender, no HSM. GU: Normal male, testes descended bilaterally; uncircumcised. Skin: Warm, no rashes. Neuro: Normal tone/strength; normal gait and coordination. MSK: No deformities; full ROM. Vision/Hearing: Grossly normal; formal screening [not documented]. Assessment 1. Well child visit, 7 years — Z00.129. Healthy child; exam reassuring; development on track. 2. Personal history of prematurity (born ~10 days early, per parent) — Z87.898. Growing and thriving without sequelae. 3. Recurrent croup, currently asymptomatic — Z87.09. Well between episodes; has home plan. 4. History of recurrent AOM s/p tympanostomy tubes — Z86.69. Right PE tube extruded and removed today; ears clear post-removal. 5. Small stature, likely constitutional — R62.52. Proportionate, active; no red flags on exam; growth percentiles [not documented]. Plan • Preventive/WCC: Discussed nutrition (protein/veg, limit sugary drinks), daily physical activity (≥60 min), screen time limits/healthy sleep routine, dental care (brush BID; dentist q6mo), and safety (helmet for wheels; booster seat until seat belt fits by height; water safety). • Immunizations: [Review record; give due vaccines incl. flu/COVID if indicated; document VIS and consent]. • Screening: Vision/hearing screening at next opportunity or per school results; dental fluoride varnish per dental home status. • Croup (recurrent): Reviewed home action plan—cool mist, calming measures; consider dexamethasone at onset of classic barky cough per prior plan [e.g., 0.6 mg/kg PO ×1, max 10 mg—confirm dosing for this patient]. Urgent care/ER if stridor at rest, persistent retractions, drooling, cyanosis, poor PO, or no improvement after steroid. Reassess if episodes become more frequent/atypical. • AOM history/PE tube: Right extruded tube removed today without complication; no drops needed given normal exam and no otorrhea. Dry ear precautions today; return for fever, otalgia, drainage, or hearing concerns. • Small stature: Encourage balanced diet and regular activity; obtain/review growth chart at next visit. If crossing percentiles or growth velocity low, consider initial work-up (TSH/FT4, CBC, CMP, celiac panel, IGF-1/IGFBP-3) and/or endocrine referral. No labs ordered today. • Follow-up: Routine WCC in 1 year, sooner PRN illness; sooner for hearing/vision screen if concerns. Procedure (today): Removal of foreign body (extruded right tympanostomy tube) from external auditory canal using alligator forceps; no anesthesia; no complications; post-procedure TM intact, canal clear; tolerated well. [CPT 69200—verify payer preference.] Coding • CPT: 99393 (established preventive, 5–11 yrs) [use 99383 if new]. + 69200 if billing ear foreign body removal. • ICD-10: Z00.129; Z87.898; Z87.09; Z86.69; R62.52.