Office Visit Note
Narrative: CHIEF COMPLAINT Well child visit with concerns about foreskin irritation, resolved motor tics, anxiety/worry, and impulse control HISTORY OF PRESENT ILLNESS Theo is a 6-year-old male presenting for a well-child visit accompanied by both parents. Several concerns were raised: 1. Foreskin irritation/penile inflammation: Parents report that approximately one week ago, Theo noted irritation at the end of his penis. Mother reports he has difficulty fully retracting his foreskin. History of summertime wet suit exposure, which is felt to be a contributing factor. 2. Motor tics (resolved): Parents noted fairly constant motor tics toward the end of the school year. These have completely resolved over the summer. Parents and clinician suspect these were a physical manifestation of anxiety/worry. 3. Anxiety/worry: Parents report Theo experiences significant worry, with both parents acknowledging a family history of anxiety. He gets caught up in topics such as severe weather and wasps (he was stung, which was genuinely frightening). He has difficulty in large group environments such as birthday parties, becoming easily upset and not yet comfortable being dropped off. He also had somatic complaints including stomachaches before camp. Parents are interested in developing coping tools for him. 4. Impulse control/behavioral maturity: Parents and his teacher note that Theo does not intend to be disruptive but that disruption occurs unintentionally. His teacher from last year described him as not coming to school trying to be disruptive but that "it just happens on accident." He tends to present behaviorally younger than his chronological age. Academically, reading and math come easily to him. He tends to form one close friendship at a time rather than broad peer groups, though he has good relationships with neighborhood children. Parents are seeking guidance on parenting strategies and are interested in therapy referral. Theo is followed by endocrinology for short stature. All growth hormone and related labs have been normal. Bone age in September was 5.5 years (approximately 8 months delayed), which the endocrinologist noted may predict later puberty. Parents report all recommended testing has been normal. REVIEW OF SYSTEMS Constitutional: No fever reported. Denies weight loss. GU: Penile/foreskin irritation reported approximately one week ago. Neurologic: Motor tics noted at end of school year, now completely resolved. Psychiatric: Worry and anxiety noted, particularly around weather and wasps; somatic stomachaches before camp; difficulty in large group social settings such as birthday parties. Denies current tics. PHYSICAL EXAM General: Well-appearing, active, playful male. Fidgety and seeking attention during visit; observed difficulty with impulse control and following redirection in office, consistent with parental report. No acute distress. Growth: Weight 42.4 lbs (below 3rd percentile, tracking consistently). Height approximately 3 feet 9.75 inches (1st percentile, consistent with prior trajectory). BMI not explicitly stated. Eyes: Intermittent independent eye movements noted; occasional subtle ocular asymmetry observed during exam. Oral: Dentition intact with two adult teeth erupted, one loose tooth, and a fused supernumerary tooth noted. Teeth overlap nicely. Cardiovascular: Normal heart sounds on auscultation. Respiratory: Clear breath sounds on auscultation of the back. Abdomen: Exam limited by significant ticklishness; no organomegaly or masses appreciated. **Genitourinary: Uncircumcised. Foreskin with limited retractability; glans able to be exposed with assistance. Mild irritation noted. No significant swelling or purulence.** Musculoskeletal/Neurologic: Normal gait getting on and off exam table. ASSESSMENT 1. Well-child visit, approximately age 6 — growth tracking below 3rd percentile for weight and at 1st percentile for height, consistent with prior trajectory. Followed by endocrinology with normal growth hormone labs and mildly delayed bone age (8 months). When adjusted for bone age, height approximates the 5th percentile. 2. Anxiety/worry — significant worry tendencies with family history of anxiety in both parents. Manifests as difficulty in large group settings, somatic complaints (stomachaches before camp), and likely contributed to resolved motor tics. Parents seeking therapeutic support and coping tools. 3. Motor tics, resolved — constant motor tics at end of school year that have completely resolved over summer. Suspected to be anxiety-related. 4. Impulse control concerns/behavioral immaturity — presenting behaviorally younger than chronological age with unintentional classroom disruption and difficulty with self-regulation, particularly when tired, stressed, or in stimulating environments. Academically performing well. 5. Foreskin irritation — acute irritation of the glans/foreskin with limited foreskin retractability, likely related to wet suit exposure during summer. Physiologic phimosis noted as age-appropriate. 6. Ocular findings — intermittent independent eye movements noted on exam with family history of myopia in both parents (mother significantly nearsighted, onset in second grade). Due for formal ophthalmologic evaluation. 7. Supernumerary fused tooth — known, monitored by dentistry; adult tooth appears normal. PLAN 1. Well-child visit/growth: Continue monitoring growth trajectory. Continue annual follow-up with endocrinology as planned. Growth hormone labs and bone age have been reassuring. No intervention needed at this time. 2. Anxiety/worry: Referral provided to therapist McCall at the neighboring practice (takes insurance). Additional therapy options discussed including a group downstairs in the building and the Ballard Clinic. Encouraged parents to prioritize fit, timing, and expense when selecting a provider. Goal is to develop individualized coping skills and techniques to manage worry, reduce somatic manifestations, and improve functioning in large group settings. Parents counseled on validating feelings while maintaining expectations (e.g., acknowledging stomachache but still attending camp). 3. Motor tics: Monitor for recurrence, particularly with return to school. If tics return, likely related to anxiety and should be addressed through the anxiety management plan. No medication indicated at this time. 4. Impulse control/behavioral concerns: Extensive anticipatory guidance provided on behavioral parenting strategies. Discussed the importance of direct, concrete communication rather than passive or question-based redirection. Counseled on setting clear expectations with defined consequences and consistent follow-through. Emphasized positive reinforcement and creating opportunities for success. Discussed that his behavioral presentation is younger than his chronological age despite strong verbal skills, and parents should parent to the behavior they observe rather than the language level. Therapist referral will also address these concerns and help determine if further evaluation for ADHD or other diagnoses is warranted. If impulse control does not improve with maturity and behavioral intervention, medication may be considered in the future, but not indicated now. 5. Foreskin irritation: Apply Neosporin or similar topical antibiotic ointment to the irritated area as needed. Practice gentle foreskin retraction during baths for hygiene. If foreskin does not begin to loosen with time and natural development, a topical steroid cream can be applied to help break down the adhesion. Parents counseled on the importance of foreskin hygiene and warning signs of infection, including significant swelling which could become a surgical urgency due to risk of strangulation. Return if worsening. 6. Vision: Recommended formal dilated eye exam given family history of early-onset myopia in both parents and subtle exam findings of intermittent ocular asymmetry. This may represent an issue at distance only. 7. No immunizations given today. ANTICIPATORY GUIDANCE Safety: Discussed street safety and playing near the cul-de-sac; reinforced clear boundaries for where and how to play around cars despite his good habits with crossing the street. Social/emotional development: Discussed age-appropriate social development including learning to form and maintain friendships, navigating peer dynamics, and the normalcy of preferring one close friend at a time. School readiness: Acknowledged strong academic performance in reading and math. Discussed that some boys are not developmentally ready for the behavioral expectations of school until age 7-8 and that this is within the range of normal. Encouraged parents to enjoy the current developmental stage and lean into age-appropriate play and silliness while maintaining reasonable behavioral boundaries. FOLLOW-UP Follow up at next well-child visit. Return sooner if foreskin irritation worsens, motor tics recur, or behavioral concerns escalate. Therapy intake recommended in the near term. ICD-10 CODES Z00.121 - Encounter for routine child health examination with abnormal findings N47.1 - Phimosis CPT CODES 99393 - Preventive visit, established patient, age 5-11 years ───────────────────────────────────────── CODES: CPT 99393 | ICD-10 Z00.121, N47.1