Pediatric Sports Medicine New Patient

I had the pleasure of seeing Alex at Regional Pediatrics on May-21-2025. My provisional diagnosis is intermittent left leg pain of unclear etiology, possibly related to growing pains.

HISTORY OF PRESENTING ILLNESS:
Alex presented with a one-month history of intermittent left leg pain, described as severe at times. The pain affects various areas of the left leg, including the ankle, shin, and knee. Episodes vary in duration, lasting from a few seconds to up to half an hour, and resolve spontaneously. There is no associated swelling, redness, or changes in gait, and walking remains unaffected. The pain has been managed with over-the-counter medications such as acetaminophen and ibuprofen, though these provide delayed relief, often after the pain has already subsided. A prior x-ray of the ankle was performed and reported as normal. No blood tests have been conducted to date. The family physician previously noted a peculiar walking pattern, though it was not specific to the left leg. The family is concerned about the cause of the pain and seeks further evaluation.

SCHOOL & SPORT PARTICIPATION:
No specific information regarding school grade or participation in sports or physical activities was provided. However, the patient’s gait remains unaffected, and walking is possible without limping.

PAST MEDICAL HISTORY:
No significant past medical history was reported. There are no known drug allergies, food allergies, or environmental allergies. Immunization status was not provided. 

Current medications reported by the patient include:
1.) Acetaminophen (as needed for pain)
2.) Ibuprofen (as needed for pain)

FAMILY AND SOCIAL HISTORY:
No specific details regarding the patient’s living situation, household members, or family medical history were provided. There is no mention of smokers in the home, siblings, or pets.

PHYSICAL EXAMINATION:
Alex appeared well and in no acute distress. Examination of the left leg revealed no swelling, warmth, decreased range of motion, or abnormalities on palpation or movement. The hip examination was normal, with no referred pain or inflammation. Overall, the physical examination was unremarkable, with no concerning findings.

IMPRESSION/PLAN:
The clinical findings suggest intermittent left leg pain of unclear etiology, possibly related to growing pains. To rule out other potential causes, I have ordered blood tests to evaluate for inflammation and other underlying conditions. 

Additionally, I have prescribed Adderall at the lowest starting dose of 10 mg to address attention-related concerns. The family has been advised to monitor for potential side effects, including dizziness and changes in appetite, and to provide updates on the medication's effectiveness and any side effects observed. 

A follow-up appointment has been scheduled in three to four months to assess Alex's weight, response to treatment, and overall progress. 

Thank you for your kind referral.

Dr. Morgan Blake  
Regional Pediatrics