Provide a SOAP note for a 10‑year‑old female presenting for an annual well‑child visit, first dose of human papillomavirus (HPV) vaccine, Vanderbilt attention‑deficit/hyperactivity disorder (ADHD) assessment due to hyperactivity and difficulty reading and focusing, with a left shoulder drop observed on scoliosis screening, and include appropriate Current Procedural Terminology (CPT) and International Classification of Diseases, Tenth Revision (ICD‑10) codes.

SOAP Note for 10-Year-Old Female: Annual Well-Child Visit with HPV Vaccine, ADHD Screening, and Scoliosis Evaluation

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SUBJECTIVE

Chief Complaint: Annual well-child visit

History of Present Illness:

• Mother reports concerns about possible ADHD: patient is "overly active," struggles with reading and focusing at school
• Teachers have also noted these difficulties
• Patient's father is currently incarcerated; patient receives therapy to address this family stressor
• No acute complaints today

Past Medical History: None

Medications: None

Allergies: No known drug allergies (NKDA)

Social History:

• Father incarcerated
• Currently in therapy

Developmental/Behavioral:

• Vanderbilt ADHD assessment completed by mother and will be obtained from teachers

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OBJECTIVE

Vital Signs: [Document height, weight, BMI percentile, blood pressure, heart rate, temperature]

Physical Examination:

• General: Well-appearing 10-year-old female, appropriate for stated age
• HEENT: Normal
• Cardiovascular: Regular rate and rhythm, no murmurs
• Respiratory: Clear to auscultation bilaterally
• Abdomen: Soft, non-tender, non-distended
• Musculoskeletal/Scoliosis Screen: Left shoulder drop noted on forward bend test
• Neurological: Alert and oriented, age-appropriate behavior observed in office
• Skin: No rashes or lesions

Vanderbilt ADHD Assessment: Completed by mother; teacher forms pending

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ASSESSMENT

1. Routine well-child visit, 10 years old – Z00.129
2. Encounter for immunization – Z23
3. Suspected attention-deficit/hyperactivity disorder – F90.9 (unspecified, pending completion of diagnostic criteria with teacher input)
4. Left shoulder asymmetry/suspected scoliosis – M41.9 (scoliosis, unspecified)
5. Counseling related to parental incarceration – Z63.79 (other stressful life events affecting family)

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PLAN

1. Well-Child Care

• Age-appropriate anticipatory guidance provided
• Discussed nutrition, physical activity, sleep hygiene, safety, and screen time
• Return for annual well-child visit in one year

2. HPV Vaccination

Administer first dose of HPV vaccine (Gardasil 9) today 1, 2. The American Cancer Society and American Academy of Pediatrics support routine HPV vaccination starting at age 9-12 years, with evidence showing that earlier vaccination (ages 9-10) may improve on-time completion rates and is at least as effective as vaccination at age 11-12 1, 3. The vaccine is administered as a 0.5 mL intramuscular injection 2.

• Schedule second dose in 6-12 months (two-dose series for patients initiating before age 15)
• Provided vaccine information statement (VIS)
• No contraindications identified

3. ADHD Evaluation

Proceed with systematic ADHD assessment per AAP/DSM-5 criteria 4. The primary care clinician should determine if DSM-5 criteria are met by documenting symptoms and impairment in more than one major setting (home and school) 4.

Next steps:

• Obtain completed Vanderbilt teacher assessment forms (minimum one teacher, preferably two if available)
• Review both parent and teacher Vanderbilt forms at follow-up visit
• Assess for DSM-5 criteria: requires 6+ symptoms of inattention and/or hyperactivity-impulsivity present for ≥6 months, with impairment in ≥2 settings, and symptoms present before age 12
• Rule out alternative causes (learning disabilities, anxiety, depression, sleep disorders, family stressors)
• Schedule follow-up visit in 2-3 weeks to review completed assessments and formulate diagnosis/treatment plan
• Continue current therapy for family stressors

4. Scoliosis Evaluation

Order AP and lateral spine radiographs (scoliosis series) to evaluate left shoulder drop and screen for structural scoliosis

• If Cobb angle ≥10 degrees, refer to pediatric orthopedics
• If Cobb angle <10 degrees, monitor with repeat examination in 6 months
• Discussed findings with mother; explained that most mild curves do not progress but require monitoring during growth

5. Psychosocial Support

• Continue current therapy related to father's incarceration
• Provided resources for family support
• Mother encouraged to maintain open communication with school

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CPT CODES

• 99384 – Initial comprehensive preventive medicine evaluation and management, new patient, age 5-11 years (if new patient) OR 99394 (if established patient)
• 90471 – Immunization administration (first vaccine component)
• 90651 – Human papillomavirus vaccine types 6,11,16,18,31,33,45,52,58 (9-valent), 2 or 3 dose schedule, for intramuscular use
• 96127 – Brief emotional/behavioral assessment (Vanderbilt ADHD forms) – may be billed per form (parent and teacher)
• 72081 – Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (scoliosis series, 2-3 views)

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ICD-10 CODES

• Z00.129 – Encounter for routine child health examination without abnormal findings (primary)
• Z23 – Encounter for immunization
• F90.9 – Attention-deficit hyperactivity disorder, unspecified (suspected, pending full evaluation)
• M41.9 – Scoliosis, unspecified (suspected based on shoulder asymmetry)
• Z63.79 – Other stressful life events affecting family and household (parental incarceration)

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FOLLOW-UP

• Return in 2-3 weeks to review completed Vanderbilt teacher assessments and discuss ADHD evaluation results
• Return for scoliosis X-ray results review (call with results or schedule visit if abnormal)
• Schedule HPV vaccine dose #2 in 6-12 months
• Annual well-child visit in one year