What E&M code would you use for this note? pt is a 9yr old female
Chief Complaint(s):
Severe cold
HPI:
ENT
Pt presents, accompanied by mom, 2 day h/o increased fatigue, low grade fever -Tmax 99, sore throat, decreased appetite, cough- non productive. Mom reports that a lot of children are sick in her class. Mom has not given her any medication. Mom would like pt to r/o for strep throat.
Current Medication:
Not-Taking/PRN
Cortisporin Otic 1%-0.35%-10000 units/mL otic solution 4 gtt 4 times a day
Medication List reviewed and reconciled with the patient
Medical History:
Repeat C-section 38+4 weeks
Birth weight 7-2; d/c weight 6-8.7
Mom's blood type A+; mild jaundice
RAD--home nebulizer
RSV bronchiolitis--1-09
heart murmur--w/u by cardiology at birth
Allergic rhinitis--cats
Allergies/Intolerance:
Cat - itchy eyes
Gyn History:
OB History:
Surgical History:
Appendectomy 09/2014
Hospitalization:
Denies Past Hospitalization
Family History:
Father: alive, Allergic to Amoxil
Mother: alive, Allergic to PCN
Siblings: alive, Sister allergic to Amox
Paternal Grand Father: deceased 40 yrs, Car acident--hit and run; very little family hx
Paternal Grand Mother: alive, Depression, Bipolar, Alcoholism
Maternal Grand Father: alive, unknown--never married to mom--no contact
Maternal Grand Mother: alive, Alcoholic, doesn
1 brother(s) , 1 sister(s) - healthy.
Social History:
no Other Tobacco use.
no Secondhand Smoke.
PCP Verification: done Do you consider Avance Care as your PCP? Yes.
Last CPE/Well-Child: done When? Date 09/2015.
Occupation: student.
no Abused.
Safe at home: yes.
Home smoke detector use: yes.
ROS:
CONSTITUTIONAL
Sick Contacts yes. Fever yes. Chills yes.
HEENT
no Runny Nose. no Ear Pain. Sore Throat yes. Cough yes. no Post-nasal Drip.
RESPIRATORY
no Nasal Congestion. no Shortness of Breath.
CARDIOVASCULAR
no Irregular Heart Beat. no Chest Pain.
GASTROINTESTINAL
no Nausea/Vomiting. no Constipation/Diarrhea. no Abdominal Pain.
SKIN
no Rash.
Objective:
Vitals:
Wt 72.2, Wt Change 4.2 lb, Ht 54, BMI 17.41, Temp(F) 100.2, HR 98, RR 18, BP(Systolic/Diastolic) 102/96
Past Results:
Examination:
ENT
Eyes: Bilateral conjunctiva without erythema or drainage.
Ears: No discharge, bilaterally tympanic membranes with good light reflex and pearly color.
Mouth: dry mucus membranes.
Throat: mild erythma, no exudates; , tonsils 2+ size.
Neck : enlarged nontender lymph nodes.
General Examination
General Appearance: well developed and well- nourished, hydrated, alert and oriented, NAD.
Heart: Regular rate and rhythm, no murmurs.
Lungs: clear to auscultation bilaterally, no wheezes/rhonchi/rales.
Abdomen: Soft, Non-tender, Non-distended with Normal Bowel Sounds, no masses palpated.
Physical Examination:
Assessment:
Assessment:
Acute pharyngitis, unspecified - J02.9 (Primary)
Plan:
Treatment:
Acute pharyngitis, unspecified
Lab:Rapid Strep (IH) (CPT 87880) Negative Result neg
Control pos
Lab:Culture, Throat (DP 10) (CPT 87070)
Notes: Rapid strep negative. Will send for cx. Will notify mom of results. Mom to alterante children's tylenol and children's motrin every 3-4 hrs for fever and pain. Mom to push fluids to maintain hydration. Mom to call with any questions or concerns. Mom voiced understanding to plan.
Procedures:
Immunizations:
Therapeutic Injections:
Diagnostic Imaging:
Lab Reports:
Preventive Medicine:
Next Appointment:
as scheduled
Thank you
Chief Complaint(s):
Severe cold
HPI:
ENT
Pt presents, accompanied by mom, 2 day h/o increased fatigue, low grade fever -Tmax 99, sore throat, decreased appetite, cough- non productive. Mom reports that a lot of children are sick in her class. Mom has not given her any medication. Mom would like pt to r/o for strep throat.
Current Medication:
Not-Taking/PRN
Cortisporin Otic 1%-0.35%-10000 units/mL otic solution 4 gtt 4 times a day
Medication List reviewed and reconciled with the patient
Medical History:
Repeat C-section 38+4 weeks
Birth weight 7-2; d/c weight 6-8.7
Mom's blood type A+; mild jaundice
RAD--home nebulizer
RSV bronchiolitis--1-09
heart murmur--w/u by cardiology at birth
Allergic rhinitis--cats
Allergies/Intolerance:
Cat - itchy eyes
Gyn History:
OB History:
Surgical History:
Appendectomy 09/2014
Hospitalization:
Denies Past Hospitalization
Family History:
Father: alive, Allergic to Amoxil
Mother: alive, Allergic to PCN
Siblings: alive, Sister allergic to Amox
Paternal Grand Father: deceased 40 yrs, Car acident--hit and run; very little family hx
Paternal Grand Mother: alive, Depression, Bipolar, Alcoholism
Maternal Grand Father: alive, unknown--never married to mom--no contact
Maternal Grand Mother: alive, Alcoholic, doesn
1 brother(s) , 1 sister(s) - healthy.
Social History:
no Other Tobacco use.
no Secondhand Smoke.
PCP Verification: done Do you consider Avance Care as your PCP? Yes.
Last CPE/Well-Child: done When? Date 09/2015.
Occupation: student.
no Abused.
Safe at home: yes.
Home smoke detector use: yes.
ROS:
CONSTITUTIONAL
Sick Contacts yes. Fever yes. Chills yes.
HEENT
no Runny Nose. no Ear Pain. Sore Throat yes. Cough yes. no Post-nasal Drip.
RESPIRATORY
no Nasal Congestion. no Shortness of Breath.
CARDIOVASCULAR
no Irregular Heart Beat. no Chest Pain.
GASTROINTESTINAL
no Nausea/Vomiting. no Constipation/Diarrhea. no Abdominal Pain.
SKIN
no Rash.
Objective:
Vitals:
Wt 72.2, Wt Change 4.2 lb, Ht 54, BMI 17.41, Temp(F) 100.2, HR 98, RR 18, BP(Systolic/Diastolic) 102/96
Past Results:
Examination:
ENT
Eyes: Bilateral conjunctiva without erythema or drainage.
Ears: No discharge, bilaterally tympanic membranes with good light reflex and pearly color.
Mouth: dry mucus membranes.
Throat: mild erythma, no exudates; , tonsils 2+ size.
Neck : enlarged nontender lymph nodes.
General Examination
General Appearance: well developed and well- nourished, hydrated, alert and oriented, NAD.
Heart: Regular rate and rhythm, no murmurs.
Lungs: clear to auscultation bilaterally, no wheezes/rhonchi/rales.
Abdomen: Soft, Non-tender, Non-distended with Normal Bowel Sounds, no masses palpated.
Physical Examination:
Assessment:
Assessment:
Acute pharyngitis, unspecified - J02.9 (Primary)
Plan:
Treatment:
Acute pharyngitis, unspecified
Lab:Rapid Strep (IH) (CPT 87880) Negative Result neg
Control pos
Lab:Culture, Throat (DP 10) (CPT 87070)
Notes: Rapid strep negative. Will send for cx. Will notify mom of results. Mom to alterante children's tylenol and children's motrin every 3-4 hrs for fever and pain. Mom to push fluids to maintain hydration. Mom to call with any questions or concerns. Mom voiced understanding to plan.
Procedures:
Immunizations:
Therapeutic Injections:
Diagnostic Imaging:
Lab Reports:
Preventive Medicine:
Next Appointment:
as scheduled
Thank you