A new 5-year-old patient presents for a routine child health examination. All recommended elements of a preventive medicine service for a 5-year-old are provided, and immunization records from the child’s previous physician are reviewed to verify the child’s immunizations are up to date.

At the same encounter, the parents ask the pediatrician for advice on management of perennial allergies (currently well controlled) and note concerns with continued long-term daily use of an over-the-counter oral antihistamine and corticosteroid nasal spray (as needed) as directed by the child’s former physician 1 month ago. The pediatrician spends 15 minutes beyond the conclusion of the preventive medicine service face-to-face with the patient and parents reviewing past health records and obtaining additional history related to the problem; discussing management options, including future allergy testing and treatment; and obtaining the parents’ agreement to the plan of care.

The history obtained and documented supports a detailed history...

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