S: 22 month old male patient presents to clinic to follow up from his 12/28 sick visit for

bilateral otitis media. He was prescribed Amoxicillin for 10 days. Patient's current
temperature is 97 F, and mother states that the infection seems to be cleared. .
O: Bilateral TM's pearly grey and no drainage, clear breath sounds, normal heart rate and
rhythm.
A: Bilateral Otitis Media (resolved)
P: Avoid showers, and smoke exposure. Watch for signs of ear infection, including trouble
eating, drinking, or sleeping. Chewing, sucking, and lying down can cause painful pressure
changes in the middle ear. Return to clinic for 24 month visit, or sooner if concerns arise.

S: 26 month old female with fever, barking cough, and congestion for 3 days presents to the
clinic. Mother states the highest fever was 103.0 F. Decreased appetite, no vomiting or
diarrhea, took Tylenol which helped with fever.
O:
-Vital Signs: 26 lbs, temp 97.5 F
-Physical Exam:
Heart: normal heart rate and rhythm
Lungs: clear breath sounds, barking cough
HEENT: Bilateral TM's pearly grey with no drainage.
-Diagnostics resulted: COVID/flu swab (-)
A: Croup
P:
-Medications: Dexamethasone 6mg/kg po one time.
-Education: Allow the child to breathe cool air during the night by opening a window or door.
Fever can be treated with an over-the-counter medication such as acetaminophen or
ibuprofen. Coughing can be treated with warm, clear fluids to loosen mucus on the vocal
cords. Warm water, apple juice, or lemonade is safe for children older than four months.
Frozen juice popsicles also can be given. Smoking in the home should be avoided; smoke can
worsen a child's cough. Keep the child's head elevated. A child may be propped up in bed with
an extra pillow. Pillows should not be used with infants younger than 12 months of age.
Parents may sleep in the same room with their child during an episode of croup so that they
will be immediately available if the child begins to have difficulty breathing.
-Follow-up: At 30 month visit or sooner if concerns arise. Parents should seek immediate
medical attention if, at any time, a child develops features of worsening or severe croup.
S: 3 yo female presents for well child visit, no concerns or complaints at this time.
O:
General: Child appears age appropriate. Vitals noted and stable.
Skin: Normal turgor and without lesions.
Head: Normocephalic.
Eyes: Conjunctivae noninjected; sclerae anicteric; lids without ptosis, edema, or erythema;
extraocular movements intact; pupils equal, round, and reactive to light. Red reflex present
bilaterally. Symmetric light reflex.
ENT: TMs gray, sharp landmarks, mobile. Nose clear. Palate is complete. Dentition normal for
age. Tonsils small and non-inflamed bilaterally.
Lymph Nodes: No significant lymphadenopathy.
Thyroid: No thyromegaly; trachea midline without masses.
Breasts: Without lesions or drainage.
Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. Peripheral
pulses are equal. There is no clubbing, cyanosis or edema of the extremities. Extremities are
warm and well perfused and capillary refill is less than 2 seconds.
Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes,
crackles, rales, rhonchi, or retractions.
Abdomen: Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound.
No masses palpable. No distention.
Genitalia: Normal female external genitalia.
Spine: Straight with no lesions.
Joints: Full range of motion about all joints.
Extremities: Digits and nails are normal
Gait: Normal and appropriate gait for age.
Mental Status: Alert, oriented, in no distress. Appropriate for age.
A:
(Z00.129) Encounter for routine child health examination without abnormal findings.
(99382)
P:
-Medications: Parent declined flu and covid vaccine, no other vaccines due at this time.
-Education: Limit screen time to less than 1 hour a day, limit sugary sweets and fast food.
Attend regular dental checkups, and brush teeth with fluoride toothpaste 2x daily, practice
water safety begin swimming lessons.
-Follow-up: Return to clinic for 4 year well child visit or sooner if concerns arise.
S: 5-year-old female presents to clinic for annual wellness exam with mother.
O: General: Child appears age appropriate. Vitals noted and stable.
Skin: Normal turgor and without lesions.
Head: Normocephalic.
Eyes: Conjunctivae noninjected; sclerae anicteric; lids without ptosis, edema, or erythema;
extraocular movements intact; pupils equal, round, and reactive to light. Symmetric light
reflex, normal fundi.
ENT: TMs gray, sharp landmarks, mobile. Nose clear. Palate is complete. Dentition normal for
age. Tonsils small and non-inflamed bilaterally.
Lymph Nodes: No significant lymphadenopathy.
Thyroid: No thyromegaly; trachea midline without masses.
Breasts: Without lesions or drainage.
Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. Peripheral
pulses are equal. There is no clubbing, cyanosis or edema of the extremities. Extremities are
warm and well perfused and capillary refill is less than 2 seconds.
Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes,
crackles, rales, rhonchi, or retractions.
Abdomen: Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound.
No masses palpable. No distention.
Genitalia: Normal female external genitalia.
Spine: Straight with no lesions.
Joints: Full range of motion about all joints.
Extremities: Digits and nails are normal
Gait: Normal and appropriate gait for age.
Mental Status: Alert, oriented, in no distress. Appropriate for age.
Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age.
A: Z00129: Encounter for routine child health examination without abnormal findings
P: Normal growth and development
Injury prevention and health promotion issues discussed.
No immunizations given today. Side effects, risks, and benefits of immunizations discussed.
Return to clinic at 6 years of age, or sooner if concerns arise. Approved for all routine
preventive medicine services, including immunizations. Abuse/neglect, functional status,
nutrition and pain assessed and no further evaluation is needed.

S: 10 year old female presents to clinic with complaints of left shoulder pain for the last 3
days. She states its a dull achy pain that limits her rom. The pain began at cheer practice
when she was doing a back hand spring and heard a pop.
O: Left shoulder ROM limited by pain, no redness or swelling to the area, clear breath sounds,
normal heart rate and rhythm.
A: 25512: Pain in left shoulder
P: Ibuprofen BID x 3days, if no improvement follow up with ortho. Otho referral given.
S: 3 yo female presents for well child visit, no concerns or complaints at this time.

O:
General: Child appears age appropriate. Vitals noted and stable.
Skin: Normal turgor and some dry, hypo pigmented patches noted around right temple.
Head: Normocephalic.
Eyes: Conjunctivae noninjected; sclerae anicteric; lids without ptosis, edema, or erythema;
extraocular movements intact; pupils equal, round, and reactive to light. Red reflex present
bilaterally. Symmetric light reflex.
ENT: TMs gray, sharp landmarks, mobile. Nose clear. Palate is complete. Dentition normal for
age. Tonsils small and non-inflamed bilaterally.
Lymph Nodes: No significant lymphadenopathy.
Thyroid: No thyromegaly; trachea midline without masses.
Breasts: Without lesions or drainage.
Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. Peripheral
pulses are equal. There is no clubbing, cyanosis or edema of the extremities. Extremities are
warm and well perfused and capillary refill is less than 2 seconds.
Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes,
crackles, rales, rhonchi, or retractions.
Abdomen: Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound.
No masses palpable. No distention.
Genitalia: Normal female external genitalia.
Spine: Straight with no lesions.
Joints: Full range of motion about all joints.
Extremities: Digits and nails are normal
Gait: Normal and appropriate gait for age.
Mental Status: Alert, oriented, in no distress. Appropriate for age.

A:
L209: Atopic dermatitis, unspecified
Z00121: Encounter for routine child health examination with abnormal findings

P:
L209: Atopic dermatitis, unspecified- no hot water-take warm baths, use mild soap, moisturize
regularly and immediately after baths to maintain skin barrier. Avoid known irritants.
Z00121: Encounter for routine child health examination with abnormal finding- Parent
declined flu and covid vaccine, no other vaccines due at this time.
limit screen time to less than 1 hour a day, limit sugary sweets and fast food. Attend regular
dental checkups, and brush teeth with fluoride tooth paste 2x daily, practice water safety
begin swimming lessons. Return to clinic for 4 year well child visit or sooner if concerns arise.
S: 3 yo female presents for well child visit, no concerns or complaints at this time.

O:
General: Child appears age appropriate. Vitals noted and stable.
Skin: Normal turgor and without lesions.
Head: Normocephalic.
Eyes: Conjunctivae noninjected; sclerae anicteric; lids without ptosis, edema, or erythema;
extraocular movements intact; pupils equal, round, and reactive to light. Red reflex present
bilaterally. Symmetric light reflex.
ENT: TMs gray, sharp landmarks, mobile. Nose clear. Palate is complete. Dentition normal for
age. Tonsils small and non-inflamed bilaterally.
Lymph Nodes: No significant lymphadenopathy.
Thyroid: No thyromegaly; trachea midline without masses.
Breasts: Without lesions or drainage.
Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. Peripheral
pulses are equal. There is no clubbing, cyanosis or edema of the extremities. Extremities are
warm and well perfused and capillary refill is less than 2 seconds.
Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes,
crackles, rales, rhonchi, or retractions.
Abdomen: Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound. No
masses palpable. No distention.
Genitalia: Normal female external genitalia.
Spine: Straight with no lesions.
Joints: Full range of motion about all joints.
Extremities: Digits and nails are normal
Gait: Normal and appropriate gait for age.
Mental Status: Alert, oriented, in no distress. Appropriate for age.

A: Z00129: Encounter for routine child health examination without abnormal findings

P: Flu vaccine given, no other vaccines due at this time.

limit screen time to less than 1 hour a day, limit sugary sweets and fast food. Ensure child is in
appropriate car seat. Attend regular dental checkups, and brush teeth with fluoride tooth paste
2x daily, practice water safety begin swimming lessons. Return to clinic for 4 year well child visit
or sooner if concerns arise.
S: 9 month male presents to office with mother for 9 month well visit. No concerns at this time.

O: 97F, 19lbs
General: Child appears age appropriate.
Skin: Normal turgor and without lesions.
Head: Normocephalic with age appropriate fontanelles.
Eyes: Conjunctivae noninjected; sclerae anicteric; lids without ptosis, edema, or erythema;
extraocular movements intact; pupils equal, round, and reactive to light. Red reflex present
bilaterally.
ENT: TMs gray, sharp landmarks, mobile. Nose clear. Palate is complete. Dentition normal for
age. Tonsils small and non-inflamed bilaterally.
Lymph Nodes: No significant lymphadenopathy.
Thyroid: No thyromegaly; trachea midline without masses.
Breasts: Without lesions or drainage.
Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. Peripheral
pulses are equal. There is no clubbing, cyanosis or edema of the extremities. Extremities are
warm and well perfused and capillary refill is less than 2 seconds.
Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes,
crackles, rales, rhonchi, or retractions.
Abdomen: Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound. No
masses palpable. No distention.
Genitalia: Normal male external genitalia; testes descended bilaterally; no hernia.
Spine: Straight with no lesions.
Joints: Full range of motion about all joints.
Extremities: Digits and nails are normal
Gait: Normal and appropriate gait for age.
Mental Status: Alert, oriented, in no distress. Appropriate for age.
Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age.

A: Z00129: Encounter for routine child health examination without abnormal findings

P: Normal growth and development

Injury prevention and health promotion issues discussed.
No immunizations given today. Side effects, risks, and benefits of immunizations discussed.
Return to clinic at 12 months of age, or sooner if concerns arise. Approved for all routine
preventive medicine services, including immunizations. Abuse/neglect, functional status,
nutrition and pain assessed and no further evaluation is needed.
S: 16-year-old female patient presents to clinic for sports physical. No concerns at this time.
O:
Vital Signs: 97.5 F, 96/70, 78bpm, 100% O2
Physical Exam:
-General: Normal general appearance. NAD.
-HEENT: Head: NC/AT. Eyes: No redness or discharge. Ears: Normal external ears. Nose:
Normal nares. Mouth and Throat: MMM. Normal gums, mucosa, palate. Good dentition.
-Cardiovascular: RRR, no m/r/g.
-Lungs: CTAB, no w/r/c.
-GI/GU: Soft, NT/ND, NBS, no masses or organomegaly.
-Skin: Warm & well perfused. No skin rashes or abnormal lesions.
-Musculoskeletal: Normal gait. No clubbing, cyanosis, or edema. Normal extremities. No
deformities.
-Neuro: No focal deficits

A:
(Z00.129) Encounter for routine child health examination without abnormal findings.
(

P:
-Clear to participate in sports activities without restrictions.
-Age appropriate anticipatory guidance provided in regards to high risk adolescent
issues. Guidance on common and less common concerns including risky behaviors (texting while
driving), drug and alcohol use, obesity, eating disorders, depression and suicidality, bullying
(especially online), sexual activity and contraception/STI prevention.
 MINE

S: -CC: 3-year female presents to the office with a skin rash on the right cheek.
-HPI: The patients mother reports a circular, dry, and scaly patch of skin on the right side of the
child's cheek.
No history of trauma or recent changes in skincare products. Denies pruritis, bleeding, or
discharge.
-PMH: No chronic medical conditions reported. Up-to-date on vaccinations. No known allergies.
-ROS: Denies recent illnesses, fevers, or weight changes. Denies any other skin abnormalities.
Denies any developmental concerns or changes.

O:
-Vital Signs: T: 98.5 F, HR: 100 bpm, RR: 24/min, BP: 90/60 mmHg, O2 Sat: 99% on room air,
Height: 90 cm (percentile: 50th), Weight: 14 kg (percentile: 60th), BMI: 15.4 kg (percentile:
70th).

-Physical Exam:
General: Well-appearing toddler, interactive.
Integumentary: Circular, dry, and scaly patch of skin on the right cheek 1 in x 1.5 in. No other
lesions noted.
Neurological: Cranial nerves intact, normal motor strength, and coordination.
Eyes, Ears, Nose, and Throat: No abnormalities noted.
Cardiovascular: Regular rhythm, no murmurs.
Respiratory: Clear breath sounds.
Abdomen: Soft, non-tender, no organomegaly.
Musculoskeletal: Full range of motion, no deformities.
Skin: Circular, dry, scaly patch on the right cheek.

A:
(B35.4) Tinea corporis.
(L20.9) Atopic dermatitis, unspecified
(99213) Office or other outpatient visit for the evaluation and management of an established
patient, which requires at least 2 of these 3 key components: An expanded problem focused
history; An expanded problem focused examination; Medical decision making of low complexity.
Counseling and coordination of care with other providers or agencies are provided consistent
with the nature of the problem(s) and the patient's and/or family's needs. Usually, the
presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes
face-to-face with the patient and/or family.

P:
-Medications: Recommend applying thing layer of over-the-counter Aquaphor and clotrimazole
antifungal cream twice her day x 1 week for potential ringworm infection.
-Education: Discussed skin care and hygiene practices. Provided education on common skin
conditions in toddlers.
-Diagnostics: None at this time. Monitor the skin condition.
-Follow-up: in 1-2 weeks if no better.
S:
-CC: Parental concern about the child's persistent pain in the right ear.
-HPI: 7 year-old female patient presents to the office with her mom for a sick visit. The childs
mother reports that she has been experiencing pain in the right ear for the past 3 days. No
recent upper respiratory tract infections reported. No history of ear drainage or hearing loss. No
fever or vomiting reported.
-PMH: No significant past medical history. Up-to-date on vaccinations. NKDA. No current
medications.
-Family History: No significant family history of ear conditions.

O:
-Vital Signs: T: 98.6F, HR: 95 bpm, RR: 18, BP: 100/60 mmHg, O2 Sat: 99% on room air, Height:
120 cm (50th percentile), Weight: 22 kg (60th percentile), BMI: 15.3 (50th perentile).

-Physical Exam:
General: Well-appearing child, interactive.
Ears: Right ear examination reveals erythema, mild swelling, and tenderness to the internal
auditory canal with a bulging, opaque, erythematous, and immobile TM. The Left ear is normal.

A:
(H65.01) Acute serous otitis media, right ear.
(99213) Office or other outpatient visit for the evaluation and management of an established
patient, with a moderate level of complexity.

P:
-Medications: Prescribed Cefdinir oral suspension, 6.2 mL by mouth (250/5 mL) once a day x 7
days for acute otitis media.
-Diagnostics: None at this time.
-Referrals: None at this time.
-Patient Education: Instruct parents on the proper administration of prescribed antibiotics.
Advised on pain management using over-the-counter acetaminophen as needed.
-Follow-up: Schedule a follow-up in 7-10 days for reevaluation or sooner if symptoms worsen.
S:
-CC: 6 year-old male here for a routine well-child visit.
-HPI: Parents report the child is meeting developmental milestones. Currently attending
kindergarten. Normal voiding and bowel patterns without daytime or nocturnal enuresis. Can
balance on one foot, hop, and skip. Can tie a knot, draws person with head/body/arms/legs,
counts to 10, and names 4+ colors.
-PMH: No significant past medical history. Up-to-date on vaccinations and will be getting next
round of vaccinations today. No known allergies.
-ROS: Parents deny recent illnesses, fevers, or weight changes. Denies headaches, seizures, and
developmental concerns. Endorse normal bowel habits without abdominal pain. Deny cough,
wheezing, shortness of breath, chest pain, palpitations, and musculoskeletal pain.

O:
-Vital Signs:
T: 98.6 F, HR: 92 bpm, RR: 20, BP: 100/60 mmHg, O2 Sat: 99% room air, Height: 110 cm
(percentile: 50th), Weight: 20 kg (percentile: 60th), BMI: 15.2 (percentile: 70th).
-Physical Exam:
General: Well-appearing child, cooperative. Neurological: Cranial nerves intact, normal motor
strength and coordination. Eyes: Visual acuity normal, no signs of redness or discharge. Ears:
Tympanic membranes clear. Nose and Throat: No congestion, tonsils normal size.
Cardiovascular: Regular rhythm, no murmurs. Respiratory: Clear breath sounds. Abdomen: Soft,
non-tender, no organomegaly. Musculoskeletal: Full range of motion, no joint abnormalities.
Skin: No rashes or lesions.

A:
(Z00.129) Routine child health examination without abnormal findings.
(99393) Periodic comprehensive preventive medicine reevaluation and management of an
individual including an age and gender appropriate history, examination,
counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of
laboratory/diagnostic procedures, established patient; late childhood (age 5 through 11 years).

P:
-Vaccines given: DTaP, Polio, MMR, Varicella. Educated parents to give age-appropriately dosed
motrin for injection site soreness and fever.
-Urinalysis: Ordered and conducted in-office as part of routine preventive care.
-Follow-up: Schedule next well-child visit in 1 year. Address any concerns or developmental
milestones at that time.
S: -CC: 9-month male well-child visit.
-HPI: Parents report that the child has been generally healthy since birth. No recent illnesses,
fevers, or concerns noted. Parents have declined all vaccinations for personal religious reasons
and signed a declination waiver.
-PMH: No significant medical history. No vaccinations received.
-ROS: Parents deny any concerns of fever, excessive crying, or irritability. Endorse normal
development and milestones. GI/GU: Deny vomiting, diarrhea, or feeding issues. Respiratory:
Deny cough, wheezing, or shortness of breath. Cardiovascular: deny cyanosis or palpitations.
Endorse a full range of joint and musculoskeletal motion, no joint abnormalities.

O: -Vital Signs: T: 98.7F, HR: 110 bpm, RR: 28, BP: 90/60 mmHg, O2 Sat: 98% on room air,
Weight: 8 kg (percentile: 50th), Length: 70 cm (percentile: 60th), Head Circumference: 47 cm
(percentile: 80th).

-Physical Exam:
General: Well-appearing infant, interactive.
Neurological: Cranial nerves intact, normal motor strength and coordination.
Head and Neck: Anterior fontanelle slightly larger than expected for age measuring approx 3
cm, but soft, and flat.
Eyes: Pupils equal and reactive, no discharge or redness.
Ears, Nose, and Throat: Tympanic membranes clear, no signs of congestion.
Cardiovascular: Regular rhythm, no murmurs.
Respiratory: Clear breath sounds.
Abdomen: Soft, non-tender, no organomegaly.
Musculoskeletal: Full range of motion, no deformities.
Skin: No rashes or lesions.

A:
(Z00121 Encounter for routine child health examination with abnormal findings.
(Q7.58) Other specified congenital malformations of skull and face bones.
(Z2882) Immunization not carried out because of caregiver refusal.
(99391) Periodic comprehensive preventive medicine reevaluation and management of an
individual including an age and gender appropriate history, examination,
counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of
laboratory/diagnostic procedures, established patient; infant (age younger than 1 year).

P:
-Education: Discussed developmental milestones and age-appropriate activities. Provided
education on nutrition and feeding guidelines. Addressed any parental concerns.
-Diagnostics: None at this time. Monitor the anterior fontanelle during subsequent visits.
-Vaccination Discussion: Respect parental decisions but discuss the importance of vaccinations
for disease prevention. Provided informational materials for the parents to consider.
-Follow-up: Schedule the next well-child visit in 3 months. Address any concerns or changes in
health at that time.
S:
-CC: Routine adolescent well-child exam for a 15 year-old female patient.
-HPI: Patient presents with her mother and reports overall good health. Menstrual cycles are
regular with no significant concerns. LMP was 1/1/24. No issues with school performance or
emotional well-being. Denies any involvement in substance use and unprotected sexual activity.
Endorses engaging in age-appropriate extracurricular activities such as cheerleading.
-PMH: No chronic medical conditions reported. Up-to-date on vaccinations. No known allergies.
-ROS: Denies recent illnesses, fevers, or weight changes, headaches, chest pain, palpitations,
shortness of breath, cough, joint/muscle pain, and symptoms of depression or anxiety.

O:
-Vital Signs: T: 98.5 F, HR: 80 bpm, RR: 18/min, BP: 110/70 mmHg, O2 Sat: 99% room air, Height:
63 inches (percentile: 75th), Weight: 121.2 lbs (percentile: 70th), BMI: 21.5 (percentile: 75th).

-Physical Exam: General: Well-appearing adolescent, cooperative. Neurological: Cranial nerves

intact, normal motor strength and coordination. HEENT: Visual acuity normal, no signs of
redness or discharge. Tympanic membranes clear, no congestion. Cardiovascular: Regular
rhythm, no murmurs. Respiratory: Clear breath sounds. Abdomen: Soft, non-tender, no
organomegaly. No CVA tenderness. Musculoskeletal: Full range of motion, no joint
abnormalities. Skin: No rashes or lesions.

A:
(Z00.129) Routine adolescent well-child exam without abnormal findings.
(99394) Periodic comprehensive preventive medicine reevaluation and management of an
individual including an age and gender appropriate history, examination,
counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of
laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years).

P:
-Vaccines given: Tdap and HPV.
-Diagnostics: Order routine blood tests and urinalysis as per standard guidelines for adolescents.
-Education: Discussed and provide education on safe sexual practices and contraception if
applicable. Assessed mental health and discuss any concerns or stresses. Provided anticipatory
guidance regarding substance use and healthy lifestyle choices.
-Follow-up: Schedule next well-child visit in 1 year. Address any concerns or changes in health at
that time.
S:
-CC: Sick visit with a sore throat for 4 days.
-HPI: A 4-year-old male patient is accompanied by his mother, presenting with a sore throat that
has persisted for 4 days. His mother reports a fever up to 102.4 degrees F and a decreased
appetite in the child. Denies vomiting, diarrhea, cough, and runny nose. Endorses being around
other sick children at preschool. Patient is up to date on all age-appropriate vaccinations.

O:
-Vital Signs: Temperature: 102 degrees F in office. Other vitals WNL.
-Physical Exam: General Appearance: Mildly lethargic. Throat: Erythema and swelling of tonsils,
presence of exudate and red and white spots in the oropharynx wall. Cervical lymph nodes:
Palpable and tender. Cardiovascular: RRR, no murmurs. Lungs: clear without wheezing. GI/GU:
bowel sounds present without organomegaly and tenderness.
-Diagnostics: Strep PCR in office: Positive.

A:
(J02.0) Streptococcal Pharyngitis.
(87880) Infectious agent antigen detection by immunoassay with direct optical observation;
Streptococcus, group A.
(99213) Office or other outpatient visit for the evaluation and management of an established
patient, which requires at least 2 of these 3 key components: An expanded problem focused
history; An expanded problem focused examination; Medical decision making of low complexity.
Counseling and coordination of care with other providers or agencies are provided consistent
with the nature of the problem(s) and the patient's and/or family's needs. Usually, the
presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes
face-to-face with the patient and/or family.

P:
-Medications: Prescribed a course of antibiotics- Amoxicillin, 10.2 mL oral suspension (400
mg/5mL) once a day for 10 days for streptococcal pharyngitis (patient weighs 16.3 kg).
-Patient Education: Recommend supportive care of rest, increased fluid intake, and over-the-
counter pain relievers such as motrin. Provided guidance on managing fever and monitoring for
any complications. Advised the mother on contagiousness and the importance of completing
the antibiotic course.
-Follow-up: Schedule a follow-up visit if symptoms persist or worsen.
S:
-CC: 6 month old routine well-child exam.
-HPI: 6 month old male infant presents for his well child exam with his mother. His parent
reports that the patient has been generally healthy since birth. Meeting developmental
milestones for age. Breastfeeding well, transitioning to solid foods. Sleeping 8-10 hours at night.
-PMH: No significant medical history. Up-to-date on vaccinations. No known allergies.
-ROS: No concerns of fever, excessive crying, or irritability. Normal bowel movements, no
concerns with urination. Sleeping well at night.

O:
-Vital Signs:
T: 98.8F, HR: 120 bpm, RR: 30, BP: 90/50 mmHg, O2 Sat: 99% in room air, Weight: 7.5 kg
(percentile: 50th), Length: 68 cm (percentile: 75th), Head Circumference: 43 cm (percentile:
60th).

-Physical Exam:
General: Well-appearing infant, alert and interactive.
HEENT: Normocephalic, fontanelles soft, no abnormalities. Eyes: Pupils equal and reactive, no
discharge or redness. Ears: Tympanic membranes clear. Nose and Throat: No signs of congestion
or throat abnormalities.
Cardiovascular: Regular rhythm, no murmurs.
Respiratory: Clear breath sounds.
Abdomen: Soft, non-tender, no organomegaly.
Musculoskeletal: Full range of motion, no deformities.
Skin: No rashes or lesions.

A:
(Z00.129) Routine well-child exam without abnormal findings.
(99391) 99391: Periodic comprehensive preventive medicine reevaluation and management of
an individual including an age and gender appropriate history, examination,
counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of
laboratory/diagnostic procedures, established patient; infant (age younger than 1 year).

P:
-Vaccines given: Pentavalent (DTaP-Hib-IPV-HepB), PCV13, Rotavirus.
-Screening: Discussed age-appropriate feeding and developmental milestones. Provided
anticipatory guidance on infant care, safety, and childproofing. Educated parents on the
importance of tummy time for motor development.
-Diagnostics: Ordered routine blood tests as per standard guidelines for infants. Discussed
upcoming vaccinations and schedule future appointments.
-Follow-up: Schedule next well-child visit at 9 months. Address any concerns or changes in
health at that time.
S:
- CC: Parental concern about their 3 year-old child female having constipation and stomach pain.
- HPI: Parents report that the child has been experiencing constipation for the past 5 days. The
child endorses having stomach pain, especially during bowel movements. Parents endorse the
childs last bowel movement was 2 days ago and was hard, formed, pebble-type stools. Parents
deny seeing blood in the stool, vomiting or diarrhea. Deny any recent dietary changes or recent
travel. Deny fever, weight loss, fatigue.
- PMH: No significant past medical history. Up-to-date on vaccinations. NKDA. No current
medications or vitamins.
- Family History: No significant family history of gastrointestinal conditions.

O:
-Vital Signs: T: 98.4 F, HR: 105 bpm, RR: 22, BP: 88/55 mmHg, O2 Sat: 99% room air.
-Physical Exam:
General: Well-appearing child, interactive.
Heart: RRR, no murmurs.
Lungs: Clear.
Abdomen: Hypoactive bowel sounds in lower quadrants. Soft, non-tender. Slight distention
noted without palpable masses. No guarding or rebound tenderness. No CVA tenderness.

A:
(K59.0) Constipation.
(99213) Office or other outpatient visit for the evaluation and management of an established
patient, with a moderate level of complexity.

P:
- Medications: Prescribed over-the-counter laxative powder, Miralax 5.2 g/day dissolved in 4-8
oz of water or juice and drink once a day for 1-3 days for constipation.
- Diagnostics: None at this time.
- Referrals: None at this time.
- Patient Education: Encouraged the parents to increased the childs fiber intake, water
consumption, and physical activity. Discussed age-appropriate toilet training strategies.
- Follow-up: in 2 weeks for reevaluation if symptoms persist.
S:
-CC: 5 year old male well-child visit with parent concerns about nighttime behaviors.
-HPI: Mother reports that the child refuses to sleep in his own bed at night and has occasional
nocturnal enuresis despite being potty trained and without accidents during the daytime or
naps. No other significant health concerns or illnesses reported.
-PMH: No chronic medical conditions reported. Up-to-date on vaccinations. NKDA.
-ROS: Denies recent illnesses, fevers, or weight changes. Denies headaches, seizures, or
developmental concerns. Denies abdominal pain or changes in bowel habits.
Denies cough, wheezing, shortness of breath, chest pain or palpitations.

O:
-Vital Signs: T: 98.5F, HR: 85 bpm, RR: 20/min, BP: 95/60 mmHg, O2 Sat: 98% on room air,
Height: 110 cm (percentile: 50th), Weight: 18 kg (percentile: 60th), BMI: 16.4 kg (percentile:
70th).

-Physical Exam:
General: Well-appearing child, cooperative.
Neurological: Cranial nerves intact, normal motor strength, and coordination.
Eyes: Visual acuity normal.
Ears, Nose, and Throat: Tympanic membranes clear, no signs of congestion.
Cardiovascular: Regular rhythm, no murmurs.
Respiratory: Clear breath sounds.
Abdomen: Soft, non-tender, no organomegaly.
Musculoskeletal: Full range of motion, no deformities.
Skin: No rashes or lesions.

A:
(Z00.129) Encounter for routine child health examination without abnormal findings.
(N39.44) Nocturnal enuresis.
(99393) Periodic comprehensive preventive medicine reevaluation and management of an
individual including an age and gender appropriate history, examination,
counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of
laboratory/diagnostic procedures, established patient; late childhood (age 5 through 11 years).

P:
-Vaccines given: DTap, MMR, Varicella.
-Education: Discussed sleep hygiene and establish a consistent bedtime routine. Inquired about
any recent stressors or changes that might affect sleep. Provided education on nocturnal
enuresis management.
-Diagnostics: None at this time.
-Referral: Consider referral to a pediatric sleep specialist if sleep issues persist.
-Follow-up: Schedule next well-child visit in 1 year. Address any ongoing sleep concerns or
changes in health at that time.