Office Visit Note
Orders Problem: Back pain Past: Chest wall deformity (pectus) Social: Student, starting high school next week Habits: Screen use at night Med: Sertraline, every morning Data: Oura ring has been used for a few months for heart rate and sleep tracking. Assessplan: Low back pain Followup: Follow up in 2-4 weeks regarding response to guanfacine dosing change. Re-engage with physical therapy for back assessment/treatment. Follow up sooner if back pain worsens, breathing symptoms increase, or albuterol use escalates. Orders Problem: Sleep difficulty Past: Chronic back pain Social: Participates in swimming and mountain biking Habits: Sleep schedule remains inconsistent during summer Med: Guanfacine, 2 mg nightly Data: Family reports available data supports that he does not consistently get enough sleep. Assessplan: Insomnia / poor sleep Problem: Mood/medication discussion Past: Poor sleep/insomnia concern Social: Plays video games with friends Med: Magnesium supplement, nightly Data: Prior guanfacine dose was 3 mg; over the summer it was reduced to 2 mg and behavior was felt to remain acceptable. Assessplan: Shortness of breath with exercise / probable exercise-induced bronchospasm; possible vocal cord dysfunction Problem: Exercise-related breathing symptoms Past: Prior shoulder pain treated with physical therapy Social: Maintains friendships in person and online Med: Albuterol inhaler, 2 puffs prior to exercise Data: Prior physical therapy was completed for shoulder pain; he attended about 3 sessions. Assessplan: Behavioral dysregulation / impulsivity Problem: Chest wall symptoms Past: Behavioral dysregulation/impulsivity discussed previously Data: Clinically discussed that chest wall popping is likely from rib-sternal joints and can become inflamed (costochondritis). Assessplan: Chest wall deformity (pectus) Problem: Warts / skin concerns Past: Recurrent warts Data: Clinically discussed that the throat-closing sensation during swimming could represent vocal cord dysfunction. Assessplan: Viral warts Problem: Social/school Data: Clinically discussed that back X-rays would not be helpful; MRI would be the next imaging modality if needed, though not indicated at this time. Assessplan: Umbilical lesion Data: Clinically discussed that repeated freezing of warts has not been effective and alternative dermatologic therapy such as Candida antigen immunotherapy may be preferable; fluorouracil was discussed as a more destructive option to avoid. Data: Clinically discussed that the umbilical lesion may represent an old umbilical granuloma.