julieordway
Networker
Wanted input on if this visit would be a 99213 or 99214. Thanks!
1 year old Established patient.
CC: Fever, Constipation
Reported by parent.
Notes:
Saturday night patient woke up at 0200 extremely fussy and inconsolable. The next day she seemed much better but that evening at 7pm again she became inconsolable, screaming and crying. She fell asleep for 90 minutes and then woke up screaming again. MOC took her to ER, they felt her belly was concerning so they got an abdominal XR which showed moderate stool burden. THe ER also performed an ultrasound to r/o intussusception which was not seen on US. She was given a glycerin suppository without a response, followed by an enema without response. She was discharged home on 1/4 cap ful of Miralax once daily. She has had one soft stool yesterday x 1 and no stools today. She is having a lot of flatulence currently. Last night again she woke up screaming and crying for 1-2 hours intermittently all night long. MOC was surprised to hear that her XR shows constipation because she normally stools three times daily and with all meals and her stools are mushy consistency.
MOC dropped her off at daycare today but then this afternoon she had a fever of 101.9F. MOC gave Motrin just before coming here. She has clear runny nose, she is teething (molars). Not pulling ears, no coughing, no foul smelling urine. No history of UTI in the past.
A&P:
Constipation-
Constipation noted on abdominal film taken yesterday at Children's Hospital. Moderate stool burden noted on radiology read. Recommend increasing miralax to 1/2 cap once daily and up to twice dialy until she begins to stool, then back off to 1/4 cap once daily until she is adequately cleaned out. She may also try a pediatric fleets enema once tonight if needed. She may also try knee-to-chest positions, warm baths, high fiber, and the "P" fruits (prunes, pears, plums). No concern for acute surgical abdomen at this time, reviewed when to consider an ER evaluation. No concern for UTI at this time.
K59.00: Constipation, unspecified
2. Fever-
Fever began today, on exam she appears to have an emerging upper respiratory infection with new onset rhinorrhea that is likely the cause of fever.
R50.9: Fever, unspecified
3. Viral upper respiratory tract infection-
Supportive home care discussed and return precautions reviewed.
J06.9: Acute upper respiratory infection, unspecified
Patient Instructions
Return in 2-3 days for ongoing fever or worsening symptoms. She should be evaluated if her fever persists for 5 days.
Return to ER for worsening abdominal pain, abdominal distension, tenderness on exam, currant jelly stools, intractable pain, or concerns of worsening condition.
1 year old Established patient.
CC: Fever, Constipation
Reported by parent.
Notes:
Saturday night patient woke up at 0200 extremely fussy and inconsolable. The next day she seemed much better but that evening at 7pm again she became inconsolable, screaming and crying. She fell asleep for 90 minutes and then woke up screaming again. MOC took her to ER, they felt her belly was concerning so they got an abdominal XR which showed moderate stool burden. THe ER also performed an ultrasound to r/o intussusception which was not seen on US. She was given a glycerin suppository without a response, followed by an enema without response. She was discharged home on 1/4 cap ful of Miralax once daily. She has had one soft stool yesterday x 1 and no stools today. She is having a lot of flatulence currently. Last night again she woke up screaming and crying for 1-2 hours intermittently all night long. MOC was surprised to hear that her XR shows constipation because she normally stools three times daily and with all meals and her stools are mushy consistency.
MOC dropped her off at daycare today but then this afternoon she had a fever of 101.9F. MOC gave Motrin just before coming here. She has clear runny nose, she is teething (molars). Not pulling ears, no coughing, no foul smelling urine. No history of UTI in the past.
A&P:
Constipation-
Constipation noted on abdominal film taken yesterday at Children's Hospital. Moderate stool burden noted on radiology read. Recommend increasing miralax to 1/2 cap once daily and up to twice dialy until she begins to stool, then back off to 1/4 cap once daily until she is adequately cleaned out. She may also try a pediatric fleets enema once tonight if needed. She may also try knee-to-chest positions, warm baths, high fiber, and the "P" fruits (prunes, pears, plums). No concern for acute surgical abdomen at this time, reviewed when to consider an ER evaluation. No concern for UTI at this time.
K59.00: Constipation, unspecified
2. Fever-
Fever began today, on exam she appears to have an emerging upper respiratory infection with new onset rhinorrhea that is likely the cause of fever.
R50.9: Fever, unspecified
3. Viral upper respiratory tract infection-
Supportive home care discussed and return precautions reviewed.
J06.9: Acute upper respiratory infection, unspecified
Patient Instructions
Return in 2-3 days for ongoing fever or worsening symptoms. She should be evaluated if her fever persists for 5 days.
Return to ER for worsening abdominal pain, abdominal distension, tenderness on exam, currant jelly stools, intractable pain, or concerns of worsening condition.