Well Adolescent (AWJ)

Lucas Vance attends for a 15 year well-child examination.

Past And Current Medical Problems

Crohn's disease: Diagnosed at age 13, followed by pediatric GI. Currently in clinical remission on infliximab (Remicade®) 300 mg IV q8w (last infusion 12/02/2026). Takes cholecalciferol (vitamin D3) 1,000 IU PO daily.

Acute Problems Or Concerns Today

Intermittent postprandial bloating and mild cramping 1-2x/week, particularly after high-dairy meals. Denies hematochezia, nocturnal diarrhea, weight loss, or fevers.

Review Of Diet/Nutrition

Eats 3 meals daily plus afternoon snacks. Good intake of lean proteins and cooked vegetables; avoids raw fibrous vegetables and popcorn due to Crohn's history. Consumes cow's milk and cheese daily. Drinks 1.5 L water/day; avoids caffeinated and carbonated beverages.

Review Of Physical Activity

Plays JV soccer (practices 4x/week for 90 mins). Rides bike on weekends. No exercise intolerance or joint pain.

Education & Employment

10th grade. Academic performance is satisfactory (A/B student). No behavioural, learning, or attention issues.

Does not receive SPED support. Has a 504 plan in place for unrestricted bathroom access and excused absences for GI infusions.

Plans to attend a 4-year university to study computer science.

Screen Time

3 hours per day on weekdays (phone and gaming), 4-5 hours per day on weekends.

Home & Environment

Lives at home with mother, father, and 12-year-old sister.

Smoke exposure: No

Guns in household: No firearms in the home.

Review Of Sleep

Sleeps 7.5-8 hours nightly. Usual bedtime 22:30, wakes at 06:30. Sleeps through the night without awakening. No snoring.

Dental Hx

Saw a dentist 4 months ago; no caries. Brushes teeth twice daily and flosses occasionally.

Review Of Elimination

1-2 soft, formed stools daily (Bristol type 4). No straining, no constipation, no dysuria.

Physical Exam

Vitals: T 36.7 °C, HR 68 bpm, BP 112/70 mmHg, Wt 58.2 kg (50th %ile), Ht 170 cm (50th %ile), BMI 20.1 kg/m². General: Well-appearing, NAD. HEENT: Oropharynx clear, mucosa moist, no oral aphthous ulcers. Abdomen: Soft, non-distended, normoactive bowel sounds. Mild tenderness to deep palpation in RLQ, no rebound or guarding, no hepatosplenomegaly or palpable masses. Perianal: Normal inspection, no fissures, skin tags, or fistulae. Skin: No erythema nodosum or pyoderma gangrenosum.

Confidential Adolescent (14-17 yo) Findings

Home: Feels safe at home; supportive family environment.

Education: 10th grade, A/B grades. No school-related concerns, denies bullying or fighting.

Activities: JV soccer, video games, coding club. Volunteers at local animal shelter monthly; no paid employment.

Drugs: Denies tobacco smoking, vaping, alcohol, marijuana, or illicit drug use. Friends occasionally vape, but patient declines.

Sexuality and Gender: Cisgender male (he/him). Attracted to females. Never had sexual intercourse (oral, vaginal, or anal).

Reviewed abstinence, future consistent condom use for STI protection, and dual contraception methods when sexually active.

Mental Health: PHQ-9 score 1, GAD-7 score 0. Denies depression, anxiety, self-harm, or suicidal ideation. Adjusting well to chronic illness.

Assessment And Plan

Lucas Vance presents for a Well Adolescent Visit.

• Immunizations are current
• “Depression and anxiety screening was completed.
• Hearing was screened and visual acuity was assessed.
• Tuberculosis risk was reviewed.
• Anemia risk was reviewed.
• Social determinants of health were assessed and discussed using PRAPARE.
• Oral health, nutritious food choices, exercise and sleep, school progress, emotional wellbeing, family and peer relationships, stress management and decision-making, risk reduction (STIs, pregnancy, drugs, alcohol, and tobacco), and safety measures (helmet use and sun protection) were reviewed.

The next well-child examination is planned for one year from now, or earlier if needed/as outlined below."

1. Well Adolescent Exam: Growth and development appropriate for age. Encouraged reducing recreational screen time to < 2 hours/day and maintaining current sleep hygiene and physical activity. Continue dental care every 6 months.

2. Crohn's Disease: In clinical remission on infliximab 300 mg IV q8w. Continue current regimen and cholecalciferol 1,000 IU PO daily. Obtain routine surveillance labs today: CBC with diff, CMP, CRP, ESR, ferritin, and 25-OH vitamin D. Follow up with pediatric GI in 2 months as scheduled.

3. Postprandial Bloating: Likely mild secondary lactose intolerance vs IBS overlap, no red flag symptoms for IBD flare. Advised a 2-week trial of lactose-free dairy products or lactase enzyme (Lactaid®) 9,000 FCC units PO with first bite of dairy. Return sooner if persistent abdominal pain, diarrhea, or hematochezia develops.