ajhunsicker
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I need some help please with the following dictation. My physician is insisting that this is a 99204 level NP. She is arguing that the Scoliosis poses a threat to life and/or limb, therefore making it a high decision making. I have explained to the physician that the way it is worded, that it does not appear to be a treat. Am I wrong? Any input is greatly appreciated.
Initial visit. a 13+4 year-old female who is referred by her pediatrician for possible scoliosis. It was noted on routine physical exam possible scoliosis. She presents now for follow-up. She denies back pain. She participates in sports without problems.
PAST MEDICAL HISTORY: Significant for ADHD.
CURRENT MEDICATIONS: Intuniv and Hydroxyn.
ALLERGIES: NKDA.
REVIEW OF SYSTEMS: Negative.
FAMILY HISTORY: Significant for diabetes, cancer and RA.
SOCIAL HISTORY: She is a right hand dominant female.
GROWTH AND DEVELOPMENT: Normal. She has had her menstrual cycle almost for a year and a half now.
PHYSICAL EXAMINATION: This is cooperative 13+4 year-old female.
VITAL SIGNS: She is afebrile. Height is 163 cm and weight is 125.2 pounds.
PSYCHOLOGICAL ASSESSMENT: Affect is normal.
COGNITIVE ASSESSMENT: Alert and oriented x3.
LYMPHATIC SYSTEM: No palpable lymph nodes.
HEAD: Atraumatic and normocephalic.
NECK: Supple with full motion; no torticollis.
UPPER EXTREMITIES: There is full motion of the shoulders, elbows and wrists without angular deformity or limitation of motion.
SPINE: The spine shows a very mild scoliosis with no cutaneous abnormalities or dimpling. Muscle tone is normal.
NEUROLOGICAL EXAMINATION: Shows normal sensation. Examination shows deep tendon reflexes are symmetrical; motor and sensory are intact; Babinski?s are down-going. There is no spasticity. There is no clonus.
CIRCULATORY EXAMINATION: Shows good pulse and capillary refill. There is no clubbing, cyanosis or edema.
GAIT: Gait is a normal, non-antalgic, heel/toe gait. The patient can easily arise from the exam table and bend over for examination. Balance and coordination are normal.
RADIOGRAPHIC IMAGING: X-rays brought in by the patient show a 10-degree scoliosis. Risser sign was not visible on the x-ray.
IMPRESSION: SCOLIOISIS IN A SKELETALLY IMMATURE FEMALE.
RECOMMENDATIONS: I have gone over the natural history with Mom and HER. I don?t think there is any reason to restrict sports. Her scoliosis is not to a degree that we need to consider bracing. We have gone over the family history and the natural history, and any concerns regarding scoliosis. Despite the fact that she is skeletally immature, I don?t think that she is going to need brace intervention due to her degree of curve. I do think we should follow her until she reaches skeletal maturity. I have gone over this with Mom and HER. We will re-evaluate every 6 months with scoliosis x-ray at that time. We will need to pull up her x-ray from ONLINE to compare.
Initial visit. a 13+4 year-old female who is referred by her pediatrician for possible scoliosis. It was noted on routine physical exam possible scoliosis. She presents now for follow-up. She denies back pain. She participates in sports without problems.
PAST MEDICAL HISTORY: Significant for ADHD.
CURRENT MEDICATIONS: Intuniv and Hydroxyn.
ALLERGIES: NKDA.
REVIEW OF SYSTEMS: Negative.
FAMILY HISTORY: Significant for diabetes, cancer and RA.
SOCIAL HISTORY: She is a right hand dominant female.
GROWTH AND DEVELOPMENT: Normal. She has had her menstrual cycle almost for a year and a half now.
PHYSICAL EXAMINATION: This is cooperative 13+4 year-old female.
VITAL SIGNS: She is afebrile. Height is 163 cm and weight is 125.2 pounds.
PSYCHOLOGICAL ASSESSMENT: Affect is normal.
COGNITIVE ASSESSMENT: Alert and oriented x3.
LYMPHATIC SYSTEM: No palpable lymph nodes.
HEAD: Atraumatic and normocephalic.
NECK: Supple with full motion; no torticollis.
UPPER EXTREMITIES: There is full motion of the shoulders, elbows and wrists without angular deformity or limitation of motion.
SPINE: The spine shows a very mild scoliosis with no cutaneous abnormalities or dimpling. Muscle tone is normal.
NEUROLOGICAL EXAMINATION: Shows normal sensation. Examination shows deep tendon reflexes are symmetrical; motor and sensory are intact; Babinski?s are down-going. There is no spasticity. There is no clonus.
CIRCULATORY EXAMINATION: Shows good pulse and capillary refill. There is no clubbing, cyanosis or edema.
GAIT: Gait is a normal, non-antalgic, heel/toe gait. The patient can easily arise from the exam table and bend over for examination. Balance and coordination are normal.
RADIOGRAPHIC IMAGING: X-rays brought in by the patient show a 10-degree scoliosis. Risser sign was not visible on the x-ray.
IMPRESSION: SCOLIOISIS IN A SKELETALLY IMMATURE FEMALE.
RECOMMENDATIONS: I have gone over the natural history with Mom and HER. I don?t think there is any reason to restrict sports. Her scoliosis is not to a degree that we need to consider bracing. We have gone over the family history and the natural history, and any concerns regarding scoliosis. Despite the fact that she is skeletally immature, I don?t think that she is going to need brace intervention due to her degree of curve. I do think we should follow her until she reaches skeletal maturity. I have gone over this with Mom and HER. We will re-evaluate every 6 months with scoliosis x-ray at that time. We will need to pull up her x-ray from ONLINE to compare.
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