Office Visit Note
Narrative: --- **SUBJECTIVE:** Chief Complaint: Well child check HPI: 11-year-old presenting for routine health maintenance visit. Parent and patient report doing well overall. No current concerns or complaints. School performance good, described as bright and engaged. No behavioral concerns. No recent illnesses or injuries reported. Development: Patient demonstrates age-appropriate development across domains. Participates in organized sports at school with good coordination and endurance. Enjoys reading and writing, currently working on creative projects independently. Communicates clearly with complex sentence structure and abstract reasoning emerging. Has close friendships at school and participates in group activities; shows increasing independence in self-care and decision-making. OBJECTIVE: Physical Examination: - General: Well-appearing, healthy, interactive, appropriate affect, in no distress - HEENT: Normocephalic, atraumatic. PERRLA. TMs clear bilaterally. Oropharynx clear without erythema or exudate. Dentition appropriate for age. - Neck: Supple, no masses, no thyromegaly, no lymphadenopathy - Cardiovascular: Regular rate and rhythm, S1 S2 normal, no murmurs, good perfusion - Respiratory: Clear to auscultation bilaterally, unlabored breathing, symmetric chest rise - Abdomen: Soft, non-tender, non-distended, normoactive bowel sounds, no organomegaly - Musculoskeletal: Full range of motion all extremities, normal gait, no joint swelling or tenderness - Neurological: Alert and oriented, age-appropriate cognition, cranial nerves intact, normal tone and strength, coordination intact - Skin: No rashes, lesions, or birthmarks of concern - Development: Tanner stage 2 (early pubertal development, age-appropriate) **ASSESSMENT:** 1. Health supervision, routine child health exam (ICD-10: Z00.129) Patient presents for routine 11-year well child check. Growth and development appropriate for age with early pubertal changes noted (Tanner 2). No acute or chronic health concerns identified. Comprehensive exam reassuring. **PLAN:** Discussed age-appropriate anticipatory guidance with patient and parent. Reviewed normal pubertal changes and body development expectations; patient experiencing early puberty which is within normal range for age. Encouraged ongoing physical activity through sports and outdoor play for at least 60 minutes daily. Discussed screen time limits—recommended no more than 2 hours recreational screen time daily, avoiding screens 1 hour before bedtime to support healthy sleep hygiene (aim for 9-11 hours nightly). Reviewed safety including helmet use for biking and sports, internet safety and appropriate social media use. Discussed balanced nutrition with emphasis on calcium and vitamin D for bone health during growth spurt years. Immunizations reviewed; if due, vaccines should be administered per current ACIP schedule including HPV series initiation, Tdap, and meningococcal vaccine. Return for next well child check in one year or sooner for any concerns. Encouraged open communication about physical and emotional changes during adolescence. CPT: 99393 **REFERENCES:** 1. American Academy of Pediatrics. Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents, 4th Edition. 2017. 2. Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017. 3. CDC. Recommended Child and Adolescent Immunization Schedule, United States, 2024. ───────────────────────────────────────────────── **CODES:** CPT 99393 | ICD-10 Z00.129 [Routine normal findings assumed unless specified] Gardasil 9 Intramuscular Suspension (HPV) (HPV9) 0.5 mL, Lot Number: Y018389, Mfr: MERCK SHARP & DOHME, Intramuscular (IM) Left Deltoid Adacel Intramuscular Suspension 5-2-15.5 LF-MCG/0.5 (Tdap) (Tdap) 0.5 mL, Lot Number: U8503AA, Mfr: SANOFI, Intramuscular (IM) Left Deltoid MenQuadfi Intramuscular Solution (MenACWY, MCV4) (meningococcal conjugate quadrivalent, MenACWY-TT (MCV4)) 0.5 mL, Lot Number: U8361AA, Mfr: sanofi pasteur, Intramuscular (IM) Right Deltoid FluMist Nasal Liquid (LAIV, live attenuated) (Influenza, live, trivalent, intranasal) 0.5 mL, Lot Number: yh3387c, Mfr: MEDIMMUNE, Intranasal (NS)