Wiki how to score Number of presenting problem, Amount of complexity to be reviewed and Ri

saket1577

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Hi,

I have one scenario for that I want to know how to score Number of presenting problem, Amount of complexity to be reviewed and Risk. Please suggest level for E/M- ED.

CC : Headache , CP

HPI : 23year old female Having headache from past one month. it is intense in worsening . Controlled by med . feeling Nausea and Vomiting as a symptoms .

PFSH : hx of Migraine ,

Sister has history of DM

smoker



ROS : All system reviewed hence ROS is Completed.


PE : General : awake HEENT : all are normal GI : Normal Gu : Normal Neuro : Normal Immunology : RASH Eye : Pain


MDM:

CBC has done , EKG is normal and no signs of abnormality in CT. Morphine IV has given.
US is Normal and HCG quantitative shows negative pregnancy.


Assessment : Migraine
Atypical Chest Pain
Seizure
Nausea and Vomitting


Plan

Codeine PO

fioricet PO
 
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