99221 or 99223????/Neuro Inp Consult

Messages
7
Best answers
0
HPI comp

PFSH Comp

ROS Comp

Exam
GA no acute distress
HEENT mucus membranes moist, no conjunctival injection
Fundoscopic exam-optic disc sharp on L, unable to see R
CARDIO
carotids-no bruit
Heart-regular rate and rhythm+cardiac friction rub, no murmurs or gallops
Pulses-palable dorsalis pedis pulses bilaterally
MOTOR
APPEARANCE: ANORMAL BULK, +R>L postural re-emegent tremor, no fasciculations
TONE increased tone in bilateral UE with cogwheeling, bilateral LE rigid
No pronator dift, no obiting, finger taps rapid with decrement bilateraly
Strength ia all extremities

Cranial Nerves: 2
3, 4, 6
5
7
8
9, 10
11, 12 (all tested)
MS:
Orientation
Attention
Memory
Language
Fund of knowledge
(all tested)


sensory, coordination, reflexes, gait (all tested)

assessment
HX of CAD, ischemic cardiomyopathy, HTN, HLD and Parkinson's disease , s/p CABG
presenting with ptosis, found to have L upper lid pstosis, hoarse voice and L miosis on exam consistent
with Horner's syndrome. Suspect ischemic stoke occuring in morning (day before) involving L vertebral artery
(wallenberg syndrome - cardioembolic vs dissection vs. small vessel) or less likely L carotid dissection

Plan
VTE Prophyaxis: yes heparin

Dysphagia Screening was dione before any oral intake. Patient passed Dysphagia Screen

Please obtain CT head and CTA head/neck to evaluate for dissection (patient cannot get MRI)
Con't DAPT
Con't high dose statin
repeat formal swallow evaluation
neuro will cont to follow

Attending Addendum
I preformed a hx and PE of the patient, reviewed diagnostiv tests including electrolytes, renal function, glucose, calcium, complete blood count, hepatic function
coagulation studies and discussed the management with the resident. I reviewed the resident note and agree with the documented findings and plan of care.
 

Orthocoderpgu

True Blue
Messages
1,292
Location
Salt Lake City, UT
Best answers
5
99221 due to exam

The exam is no more than Detailed no matter how you view this. I looked at it from: General Multi-system exam, Neurological exam (97) and Body areas, body systems (95).
 
Top