Bernadette10
Guru
I'm thinking this would be a level 3 because of medical necessity with low risk with 2 or more self-limited or minor problems? Even though the history and exam are detailed? There's also a full past medical, family and social history which I didn't copy. We use 1995 guidelines. Thanks for any advice.
History of Present Illness
Chief complaint cough, rhinorrhea, sore throat. Feeling feverish. Symptoms x about 5-6 days. Denies ear pain. Has been using nyquil, nothing today yet.
Also states severe dandruff, has tried several otc shampoos without improvement. Denies well water. Does not use a lot of hair products.
Review of Systems PHQ Score
Initial Depression Screen Score: 0 Fatigue:yes
Body aches:no
Chills:no
Fever:feverish to touch
HA: no
Nasal congestion:yes
Rhinorrhea:yes
Cough:yes, productive
SOB:no
Wheezing:no
Sore throat:yes
Ear pain:no
Ear drainage:no
Complains of dry itchy scalp, dandruff
Physical Exam Vitals & Measurements T: 37.3 °C (Oral) HR: 70(Peripheral) BP: 114/76 SpO2: 97%
HT: 160 cm WT: 51 kg BMI: 19.92 General: Well developed, well nourished, in no acute distress
Ears: No deformity or lesion of external ear. Canals and TM appear normal bilaterally. TM’s intact, not inflamed, with normal light reflex. Hearing grossly normal to conversational speech
Nose: moderate nasal mucosa inflammation and edema, no active drainage, denies sinus tenderness
Mouth: mild pharyngeal erythema, no tonsillar enlargement, no exudate, no petechiae
Neck: shotty anterior cervical nodes bilaterally
Lungs: clear to auscultation throughout, no wheezing, no rales. No respiratory distress
Cardio: regular rate and rhythm, no murmur
Skin: Dry thick patches of dandruff to scalp throughout, is pruritic per patient.
Mental Status: alert and oriented x3, normal mood and affect given age
Assessment/Plan
1. Seborrheic dermatitis of scalp. Will try on ketoconazole shampoo. Discussed needs to use consistently. Avoid too many hair products that dry out scalp, conditioner to ends of hair only to avoid build up. Fu with PCP if not improving over next 4-6 weeks.
2. Viral upper respiratory tract infection. Discussed exam and hx are consistent with viral illness. Advised of typical duration. Discussed antibiotics unfortunately do not treat viral illnesses, it will take time to run course- usually 7-14 days. Fluids/rest encouraged, PRN tylenol/ibuprofen for any pain. May use claritin D, robitussin for symptomatic tx. Follow up with PCP if not improving over next 7 days or significantly worsening symptoms. Patient and/or parent verbalized understanding of tx plan.
Orders:
ketoconazole topical, 1 app, Topical, 2x/Wk for 8 week(s), 120 mL, Refill(s) 1, Use 2x week x 8 weeks, then prn, Walmart Pharmacy
History of Present Illness
Chief complaint cough, rhinorrhea, sore throat. Feeling feverish. Symptoms x about 5-6 days. Denies ear pain. Has been using nyquil, nothing today yet.
Also states severe dandruff, has tried several otc shampoos without improvement. Denies well water. Does not use a lot of hair products.
Review of Systems PHQ Score
Initial Depression Screen Score: 0 Fatigue:yes
Body aches:no
Chills:no
Fever:feverish to touch
HA: no
Nasal congestion:yes
Rhinorrhea:yes
Cough:yes, productive
SOB:no
Wheezing:no
Sore throat:yes
Ear pain:no
Ear drainage:no
Complains of dry itchy scalp, dandruff
Physical Exam Vitals & Measurements T: 37.3 °C (Oral) HR: 70(Peripheral) BP: 114/76 SpO2: 97%
HT: 160 cm WT: 51 kg BMI: 19.92 General: Well developed, well nourished, in no acute distress
Ears: No deformity or lesion of external ear. Canals and TM appear normal bilaterally. TM’s intact, not inflamed, with normal light reflex. Hearing grossly normal to conversational speech
Nose: moderate nasal mucosa inflammation and edema, no active drainage, denies sinus tenderness
Mouth: mild pharyngeal erythema, no tonsillar enlargement, no exudate, no petechiae
Neck: shotty anterior cervical nodes bilaterally
Lungs: clear to auscultation throughout, no wheezing, no rales. No respiratory distress
Cardio: regular rate and rhythm, no murmur
Skin: Dry thick patches of dandruff to scalp throughout, is pruritic per patient.
Mental Status: alert and oriented x3, normal mood and affect given age
Assessment/Plan
1. Seborrheic dermatitis of scalp. Will try on ketoconazole shampoo. Discussed needs to use consistently. Avoid too many hair products that dry out scalp, conditioner to ends of hair only to avoid build up. Fu with PCP if not improving over next 4-6 weeks.
2. Viral upper respiratory tract infection. Discussed exam and hx are consistent with viral illness. Advised of typical duration. Discussed antibiotics unfortunately do not treat viral illnesses, it will take time to run course- usually 7-14 days. Fluids/rest encouraged, PRN tylenol/ibuprofen for any pain. May use claritin D, robitussin for symptomatic tx. Follow up with PCP if not improving over next 7 days or significantly worsening symptoms. Patient and/or parent verbalized understanding of tx plan.
Orders:
ketoconazole topical, 1 app, Topical, 2x/Wk for 8 week(s), 120 mL, Refill(s) 1, Use 2x week x 8 weeks, then prn, Walmart Pharmacy