Office Visit Note
Narrative: CHIEF COMPLAINT Annual well-child visit with concerns about back/shoulder pain from swimming, medication management for mental health, and peer therapy evaluation HISTORY OF PRESENT ILLNESS Eamon is a 14-year-old male presenting for his annual well-child visit. He has been experiencing back and shoulder pain attributed to competitive swimming with his club team (Gators). Parents report he hunches over and appears like he's 'my age or older' after physical work like shoveling. He describes the pain as affecting the muscles in his upper back and shoulder area, predominantly the right shoulder. He received a massage for his birthday two days ago with minimal benefit. He has also been experiencing significant fatigue recently, falling asleep in class multiple times. He reports going to bed around 10-10:30 PM and falling asleep by 11 PM, waking at 7-8 AM. Regarding mental health, Eamon has been participating in the PEERS program but reports it as 'completely useless' and not addressing his needs. The program has also shifted to entirely virtual format. Parents are considering discontinuing PEERS to return focus to individual therapy with Rochelle. He is currently on sertraline and guanfacine for mood/behavioral concerns. Parents question whether medications are causing flatness or lethargy. Eamon reports feeling 'very, very tired lately' but denies feeling flat. Notably, parents report significant improvement in outbursts and angry energy over the past 1-2 months. Eamon believes the guanfacine is unnecessary and attributes behavioral improvements to maturity rather than medication. REVIEW OF SYSTEMS Constitutional: Reports significant fatigue, falling asleep in class. Denies weight changes. Musculoskeletal: Reports back muscle pain and right shoulder pain with activity. Denies joint swelling. Psychiatric: Denies feeling flat or depressed. Parents note improved emotional regulation over past 1-2 months with decreased outbursts. Genitourinary: Patient reported concern about bumps under foreskin - examined and reassured as normal. PHYSICAL EXAM Vitals: Weight 134 lbs, Height 66 inches (5'6") General: Well-appearing adolescent male, appropriately interactive. Heart rate noted to be low/athletic. HEENT: Pre-molars erupting. Braces in place, rubber bands no longer required per orthodontist. Cardiovascular: Low resting heart rate consistent with athletic conditioning. Musculoskeletal: Paraspinous muscle asymmetry noted - right side more tense and full compared to left. Bilateral trapezius muscles with significant tension and multiple palpable knots. Oblique muscles very tight. Limited flexibility on forward bend and backward extension - 'too stiff.' Arm span measured at 69 inches (5'9"). Sternum mildly asymmetric. Skin: Accessory nipple noted on chest. Genitourinary: Tanner stage 4. Normal male genitalia, no discharge, small bumps noted are normal variant/irritation. Spine: No scoliosis on forward bend. Paraspinous muscle asymmetry as noted above. ASSESSMENT 1. Well-child visit, 14-year-old male - Tanner stage 4, growth progressing appropriately 2. Musculoskeletal strain, upper back and right shoulder - related to competitive swimming, significant muscle tension and tightness throughout upper back, trapezius, and obliques; limited flexibility 3. Anxiety/behavioral disorder on sertraline and guanfacine - stable with reported improvement in outbursts over past 1-2 months; fatigue may be medication-related side effect vs normal adolescent growth 4. Fatigue - multifactorial, consider medication side effect, growth spurt, sleep quality 5. PEERS program - not meeting patient's needs, to discontinue PLAN 1. Physical therapy referral for swimmer's shoulder and upper back pain - parents to contact Dan Bielski at Odum Sports/Health and Wellness (coach-recommended, specializes in swimmers). Alternative options discussed: TCO or Institute of Athletic Medicine. Recommend comprehensive PT addressing both shoulder and back given interconnected muscle groups. 2. Home management for musculoskeletal pain: Heat application, stretching, NSAIDs (naproxen or ibuprofen) as needed for pain flares. 3. Recommend compensatory exercise program - yoga or Pilates to address muscle tightness and improve flexibility. 4. Mental health: Continue current medications (sertraline and guanfacine) unchanged for now given improved behavioral stability. Discontinue PEERS program. Resume individual therapy with Rochelle. 5. Plan to reassess medications in 2-3 months if stability continues - guanfacine would be first medication to consider weaning based on patient feedback. 6. Immunization: Administered HPV vaccine #2 today (first dose June 2024). 7. Counseled on device use: Strict screen time limits recommended using parental controls, no devices in room during restricted times, parents should know passcode, spot checks appropriate, follow on social media. 8. Encouraged in-person socialization with friends outside of school. 9. Patient advised to add medications to phone health app for emergency reference. ANTICIPATORY GUIDANCE Discussed expected continued growth (Tanner 4, not done growing). Mid-parental height calculation suggests approximately 5'9" adult height. Reviewed importance of flexibility work to complement strength training for competitive athletes. Counseled on responsible device and social media use - signed contract recommended. Encouraged face-to-face social activities with friends and girlfriend. Discussed normal sibling dynamics and praised patient's strategy of avoiding conflict with younger brother. FOLLOW-UP Return for 15-year-old well-child visit. Contact clinic sooner if shoulder/back pain worsens or mental health concerns arise. ICD-10 CODES Z00.121 - Encounter for routine child health examination with abnormal findings M54.2 - Cervicalgia M25.511 - Pain in right shoulder F41.9 - Anxiety disorder, unspecified R53.83 - Other fatigue Z71.3 - Dietary counseling and surveillance CPT CODES 99394 - Preventive visit, established patient, age 12-17