My codes: B96.2, T85.0XA, G91.9, 99285 Help me code this correctly please!
Case:
Emergency Department
CHIEF COMPLAINT
Intermittent headaches for the past 2 weeks and vomiting and lethargy for the last day.
HISTORY OF PRESENT ILLNESS
This is a 5-year-old male with myelomeningocele, ventriculoperitoneal shunt with 4 previous revisions. The last one was 3 years ago. He is currently under treatment for a UTI with Septra. For the last 2 weeks, the patient has had intermittent headaches relieved by Tylenol. He has had vomiting and lethargy for the last 24 hours. There is no history of fever, urinary tract symptoms or diarrhea. No loss of consciousness, seizure activity or visual changes.
PAST HISTORY
Immunizations: Up to date including diphtheria, tetanus and polio.
Illnesses: Product of a cesarean section for breech, remaining in neonatal ICU for 22 days. A VP shunt was placed for congenital hydrocephalus. The patient was not intubated.
Operations: Repair of myelomeningocele and vesicostomy. Ventriculoperitoneal shunt revision performed 4 times.
ALLERGIES: NO ALLERGIES.
Social history: In special school, normal development. Walks with braces.
PHYSICAL EXAMINATION
GENERAL: Sleepy, arousable, appropriate.
VITAL SIGNS: Pulse: 68. Blood pressure: 108/62. Respiratory rate: 32. Temperature: 99.8 °F. Weight: 18 kg.
HEENT: Head: Reservoir firm. Eyes: PERRL. EOMs full. Ears: Tympanic membranes clear. Nose: Clear.
NECK: Supple.
CHEST: Heart: Regular rate and rhythm without murmurs. Lungs: Clear.
ABDOMEN: Soft, normal bowel sounds. Vesicostomy. No hepatosplenomegaly.
BACK: Well-healed myelomeningocele repair scar.
EXTREMITIES: Warm. Pulses 2+. Capillary refill less than 2 seconds.
NEUROLOGIC: Moves all extremities, alert when aroused. DTRs 2+. Negative Babinski.
IMPRESSION
1. Hydrocephalus with probable ventriculoperitoneal shunt malfunction in a child with closed fontanelle.
2. Potential for rapid deterioration with increasing hydrocephalus.
3. Urinary tract infection due to Escherichia coli.
PLAN
Recommend neurosurgery consultation. Repeat urine culture, electrolytes, WBC with differential. NPO. Maintenance fluid, cardiac monitor. Continue Bactrim suspension.
Case:
Emergency Department
CHIEF COMPLAINT
Intermittent headaches for the past 2 weeks and vomiting and lethargy for the last day.
HISTORY OF PRESENT ILLNESS
This is a 5-year-old male with myelomeningocele, ventriculoperitoneal shunt with 4 previous revisions. The last one was 3 years ago. He is currently under treatment for a UTI with Septra. For the last 2 weeks, the patient has had intermittent headaches relieved by Tylenol. He has had vomiting and lethargy for the last 24 hours. There is no history of fever, urinary tract symptoms or diarrhea. No loss of consciousness, seizure activity or visual changes.
PAST HISTORY
Immunizations: Up to date including diphtheria, tetanus and polio.
Illnesses: Product of a cesarean section for breech, remaining in neonatal ICU for 22 days. A VP shunt was placed for congenital hydrocephalus. The patient was not intubated.
Operations: Repair of myelomeningocele and vesicostomy. Ventriculoperitoneal shunt revision performed 4 times.
ALLERGIES: NO ALLERGIES.
Social history: In special school, normal development. Walks with braces.
PHYSICAL EXAMINATION
GENERAL: Sleepy, arousable, appropriate.
VITAL SIGNS: Pulse: 68. Blood pressure: 108/62. Respiratory rate: 32. Temperature: 99.8 °F. Weight: 18 kg.
HEENT: Head: Reservoir firm. Eyes: PERRL. EOMs full. Ears: Tympanic membranes clear. Nose: Clear.
NECK: Supple.
CHEST: Heart: Regular rate and rhythm without murmurs. Lungs: Clear.
ABDOMEN: Soft, normal bowel sounds. Vesicostomy. No hepatosplenomegaly.
BACK: Well-healed myelomeningocele repair scar.
EXTREMITIES: Warm. Pulses 2+. Capillary refill less than 2 seconds.
NEUROLOGIC: Moves all extremities, alert when aroused. DTRs 2+. Negative Babinski.
IMPRESSION
1. Hydrocephalus with probable ventriculoperitoneal shunt malfunction in a child with closed fontanelle.
2. Potential for rapid deterioration with increasing hydrocephalus.
3. Urinary tract infection due to Escherichia coli.
PLAN
Recommend neurosurgery consultation. Repeat urine culture, electrolytes, WBC with differential. NPO. Maintenance fluid, cardiac monitor. Continue Bactrim suspension.
