DO YOU BELIEVE THIS IS A 99214/99215? THANKS 
"not feeling good"per mom per male with pt, was given a bath and then appeared limp. "like dead" episode since resolved
Vital Signs
AGE 1.6 mos
TEMPERATURE 97.8 F
WEIGHT 12/12 lbz
WEIGHT (%) 83
History of Present Illness
Intial history obtained with Dad's help but difficult to understand exactly what happened. Pt. was sleeping and then mom gave him a shower and he looked "dead". Has been sleeping more than usual. Eating- was doing OK but then when this episode happened he refused to drink. No fever.
After labs drawn (to which pt had minimal reaction) decided that should use language line.
It seems like patient was sleeping and when awakened mom decided to bath him then his eyes rolled to right - saw whites. Then he seemed "dead" ? pale - not blue per translation. Has been sleepy and not wanting to eat since then - about an hour. Unclear how long this episode lasted.
Allergies
NKA
Interval History
Hospitalization, Surgery, ER, Urgent visit since last visit? N
Physical Exam
General Appearance
WDWN, sleeping arousable but sleepy was able to feed but slowly / limp at times
Skin
mild dryness of cheeks with slight cracking/ dry lips/ pink around nares
Head
Normocephalic, atraumatic, fontanel soft
Eyes
PERRL,EOM normal
Ears
NL canals, TMs clear with normal landmarks
Nose
NL shape, no discharge
Mouth
tongue with thick white plaque/ MMM at times had difficulty with secretions - was suctioned with bulb
Throat
NL tonsils. No petechiae, exudate
Lymph Nodes
No palpable lymph nodes
Neck
Supple, no adenopathy or masses
Heart
RRR, no murmur, S1 & S2
Lungs
Clear to auscultation, no rales or wheezes, no increased resp distress
Abdomen
slightly distended but soft, non-tender, no masses. Liver/spleen not enlarged. NL bowel sounds. umbilical hernia
External Genitalia
NL external genitalia. No hernia. No discharge
Testes descended? Y
Circumcised? N
Extremity
No deformity with full range of motion
Hips
Normal without dislocation. neg ort, barlow, symmetric creases
Neurological
sleepy, limp, at times able to follow sounds and voice but then other times just drifting off - a couple of times looked like eyes deviating to the R
Assessment and Plan
Assessment:
Lethargic- ? seizure activity/infection
Plan:
After labs patient remained lethargic and decision was made to send to ED by ALS
When ALS arrived infant still very limp but after glucose checked he was more awake- spit up breast milk he had had during visit
transported to ED at LGH - Dr. Kareores made aware as was hospitalist
Did best to explain to family need for transport and they agreed
"not feeling good"per mom per male with pt, was given a bath and then appeared limp. "like dead" episode since resolved
Vital Signs
AGE 1.6 mos
TEMPERATURE 97.8 F
WEIGHT 12/12 lbz
WEIGHT (%) 83
History of Present Illness
Intial history obtained with Dad's help but difficult to understand exactly what happened. Pt. was sleeping and then mom gave him a shower and he looked "dead". Has been sleeping more than usual. Eating- was doing OK but then when this episode happened he refused to drink. No fever.
After labs drawn (to which pt had minimal reaction) decided that should use language line.
It seems like patient was sleeping and when awakened mom decided to bath him then his eyes rolled to right - saw whites. Then he seemed "dead" ? pale - not blue per translation. Has been sleepy and not wanting to eat since then - about an hour. Unclear how long this episode lasted.
Allergies
NKA
Interval History
Hospitalization, Surgery, ER, Urgent visit since last visit? N
Physical Exam
General Appearance
WDWN, sleeping arousable but sleepy was able to feed but slowly / limp at times
Skin
mild dryness of cheeks with slight cracking/ dry lips/ pink around nares
Head
Normocephalic, atraumatic, fontanel soft
Eyes
PERRL,EOM normal
Ears
NL canals, TMs clear with normal landmarks
Nose
NL shape, no discharge
Mouth
tongue with thick white plaque/ MMM at times had difficulty with secretions - was suctioned with bulb
Throat
NL tonsils. No petechiae, exudate
Lymph Nodes
No palpable lymph nodes
Neck
Supple, no adenopathy or masses
Heart
RRR, no murmur, S1 & S2
Lungs
Clear to auscultation, no rales or wheezes, no increased resp distress
Abdomen
slightly distended but soft, non-tender, no masses. Liver/spleen not enlarged. NL bowel sounds. umbilical hernia
External Genitalia
NL external genitalia. No hernia. No discharge
Testes descended? Y
Circumcised? N
Extremity
No deformity with full range of motion
Hips
Normal without dislocation. neg ort, barlow, symmetric creases
Neurological
sleepy, limp, at times able to follow sounds and voice but then other times just drifting off - a couple of times looked like eyes deviating to the R
Assessment and Plan
Assessment:
Lethargic- ? seizure activity/infection
Plan:
After labs patient remained lethargic and decision was made to send to ED by ALS
When ALS arrived infant still very limp but after glucose checked he was more awake- spit up breast milk he had had during visit
transported to ED at LGH - Dr. Kareores made aware as was hospitalist
Did best to explain to family need for transport and they agreed
