AI Scribe for Family Medicine

CHIEF COMPLAINT: 4-year well-child check; kindergarten readiness physical.

SUBJECTIVE:
4-year-old female accompanied by mother for routine well-child visit and
kindergarten entry physical. Mother reports no concerns. Child has been
well — no recent fever, vomiting, diarrhea, or sick contacts. Sleep:
9-10 hours/night, no parasomnias. Appetite normal; eats most fruits and
vegetables; 2-3 cups whole milk per day. Toilet trained day and night
since age 3. Speaks in 5-6 word sentences, telling stories, knows colors
and counts to 20. Plays well with siblings; attends preschool 3
half-days/week with no behavioral concerns. Helmet worn for biking.
Booster seat in car, rear seat. No firearms in home. Smoke detectors
working. No tobacco exposure.

Diet recall (24h): cereal + whole milk; PB&J + apple slices + milk;
chicken + rice + broccoli + water. Brushing teeth 2x daily, last dental
visit 4 months ago.

Screen time: 1 hour/day, mostly co-viewed.

Family history: Father with seasonal allergies; maternal grandmother T2DM.

OBJECTIVE:
Vitals: T 98.6 F, HR 96, RR 22, BP 92/58 (manual, R arm)
       Weight: 16.8 kg (50th %ile)
       Height: 102 cm (45th %ile)
       BMI: 16.1 (60th %ile, healthy)
Vision (LEA chart): 20/30 OD, 20/30 OS
Hearing (audiometry screen): Passed bilaterally at 1, 2, 4 kHz / 25 dB

General: Well-appearing, cooperative, age-appropriate behavior
HEENT: AFOSF n/a (closed); PERRL, EOMI, TMs pearly bilaterally with
       sharp light reflex; nares patent; OP clear; teeth without caries
Neck: Supple, no LAD, no thyromegaly
CV: RRR, no murmur, femoral pulses 2+ symmetric
Pulm: CTAB, no wheeze
Abdomen: Soft, NT, ND, no HSM, no masses
GU: Tanner 1, normal external female anatomy
MSK: Full ROM all extremities, gait stable, hops on each foot
Skin: No concerning lesions, no bruising in unusual locations
Neuro: CN II-XII grossly intact; balances on 1 foot 5 sec; copies a cross

Developmental surveillance (Bright Futures 4-year):
- Motor: Hops, balances on 1 foot, draws cross — appropriate
- Language: 5-6 word sentences, tells stories — appropriate
- Cognitive: Counts to 20, knows colors — appropriate
- Social: Cooperative play, follows multi-step directions — appropriate
- M-CHAT-R: not indicated (age >36 mo); no autism concerns

ASSESSMENT:
1. Well 4-year-old female — kindergarten ready (Z00.129)
2. Mild myopia — vision 20/30 — recheck at 5-year visit; ophthalmology
   referral if persists or worsens
3. Up-to-date immunizations except pending DTaP #5, IPV #4, MMR #2,
   Varicella #2 (4-6 year boosters due today)
4. Healthy weight, healthy diet
5. Anticipatory guidance: home/car safety, screen time, dental,
   reading aloud, kindergarten transition

PLAN:
1. Vaccines administered today: DTaP #5, IPV #4, MMR #2, Varicella #2
   (each in separate sites; informed consent obtained from mother;
   VIS sheets provided). Tylenol info reviewed for fever.
2. Vision: Recheck at 5-year well-child; ophtho referral if 20/30 or
   worse persists.
3. Dental: Continue 6-month visits; fluoride varnish applied today.
4. Anticipatory guidance reviewed: reading 20 min/day, family meals,
   1 hour active play daily, 8-13 hours sleep, screen time <1 hr/day.
5. Kindergarten form completed and given to mother.
6. Return for 5-year well-child or sooner for concerns.

CPT: 99392 (well-child, established, age 1-4)
     90460 x4 + 90461 x4 (vaccine administration with counseling)
     90700 (DTaP), 90713 (IPV), 90707 (MMR), 90716 (Varicella)
     99173 (visual acuity screen), 92551 (audiometry screen)
ICD-10: Z00.129, Z23