# ?? 99214



## HBULLOCK (Sep 9, 2010)

CAN I HAVE SOME OPINIONS ON THIS -PLEASE 99213/99214?  THANKS  
CC:from school c/o dizzy, jaw pain, "feels gross" BP standing 100/58 P 88 sitting 104/58 P 66 lying down BP 98/60 P 64

Vital Signs 
AGE 16y10.8m
TEMPERATURE 98.5 F
PULSE 88
BLOOD PRESSURE 100/58
WEIGHT 118.8 lb
WEIGHT (%) 45

History of Present Illness 
lightheaded yesterday at staples when getting out of the car. woke up this morning not feeling well, c/o jaw pain. b/l posterior jaw pain, no trauma noted. pain radiates to back of the head at times 3-4x today--felt like muscles squeezing in the back of her head, lasted for 25seconds. light-headed all day. went to school RN, laid down for a little. went home early, took a nap. pain 6/10 in jaw, max 7-8/10, min 0/10. 
--feeling nauseated in waves, no vomiting/diarrhea. abd pain with nausea like upset stomach. a little RLQ pain yesterday but resolved on its own, didn't think much of it
--yogurt earlier today, nothing to drink today except a couple sips of water. needs a note if ok to have waterbottle at school. tends to get lightheaded during illness--see also 3/10 notes when dehydrated with post-concussive syndrome, postural hypotn
--no fevers, nasal sxs, coughing, throat pain (? a little), ear pain on left earlier but went away quickly
--no known sick contacts. 
--was supposed to take tylenol earlier but didn't
meds: adderall, lamictal, ocp--no recent changes

Interval History 
Specialty appointment since last visit? Y
8/17 had right lumpectomy with dr jones--came back negative
Physical Exam 
General Appearance 
WDWN, NAD
Skin 
No cyanosis, rash, abnl pigmented lesions, normal skin turgor and capillary refill
Head 
Normocephalic, atraumatic, except anterior lower jaw with slight symmetric fullness, no bruising noted but +ttp. 
Eyes 
perrl, eomi, glasses
Ears 
NL canals, TMs clear with normal landmarks
Nose 
NL shape, no discharge
Mouth 
NL tongue, mucosa, dentition. no TMJ ttp. swelling or pain at stensons duct or salivary glands under tongue b/l, even with milking
Throat 
NL tonsils.  No petechiae, exudate
Neck 
Supple, no adenopathy or masses
Heart 
RRR, no murmur, S1 & S2. hr 85 after sitting for awhile
Lungs 
Clear to auscultation, no rales or wheezes
Abdomen 
s/nd, mild ttp RLQ with deep palpation, no r/g (c/w pain last night that had since gone away and doesn't hurt once i stop pressing). +bs. no hsm
Assessment and Plan 
Assesment 
16yr female with nausea, mild sym jaw swelling, lightheadedness.
--doubt parotiditis as no fever, swelling more anteriorly located than over parotid
--not clear gum lesions, teeth all wnl
Plan: 
--push fluids in small freq amounts, ok for gingerale/gatorade to help with nausea/lightheadness respectively. goal for 1liter over next 2hrs at home
--start motrin with fluids/food for next few days until pain/swelling improves
--dsicussed liberal use of salt in diet, importance of staying well-hydrated, esp when sick
--if no better in next few days, t/c dental or oral surgery consultation, sooner if worsening
--note for school and note to allow h20 bottle in schoolAcknowledge/Ok  Acknowledge/Next  Error  Enlarge   
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## LLovett (Sep 9, 2010)

This is a 99214 to me.

Laura, CPC, CPMA, CEMC


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## Sandy Stevens (Sep 10, 2010)

I agree Laura.
The amount of history obtained and exam performed is up to clinical judgment in order to diagnose and treat a patient.

Hx:  HPI with 4 elements, ROS >2 but <9, and pertinent medical history (at least current meds and/or reference to previous visit = Detailed History (limited by system inventory) 
Exam: 8 OS/BA = Comprehensive Exam

The nature of the problem may be self-limited/minor/transient; we don't know because it's not defined. There was no "diagnosis", only ill-defined symptoms for a new problem with no work-up, and the managements were minimal. Still, a Detailed History + Comprehensive Exam = 99214. 

Sandy


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