PLEASE SEE NOTE AND GIVE ME YOUR OPINION THANKS
- Note - Outpatient - - Notes Module
Header
Chief Complaint
seen at Lawrence General ER 7/9 after being jumped by several people,transfered to Beth Israel,told concussion, c/o nausea today with red streak down rt side of face
Vital Signs
AGE 17y9.7m
TEMPERATURE 99.9 F
BLOOD PRESSURE 120/70
WEIGHT 119.6 lb
WEIGHT (%) 8
History of Present Illness
17 yo M seen at Law general ER 3 days ago after being beaten up by several youth, transferred to BI deaconess with r/o sub dural hematoma and R mandibular fx. Had jaw surgery 7/11, seen by neuro with no focal sx and d/c to home 7/12. On oxycodone 1-2 tabs q3 for pain, keflex 500 mg q6, colace and levetiracetam 500mg BID through 7/16.
Spanish speaking mom and english speaking uncle here with patient today for redness on back of neck. Mom told to have him seen if neck turns red near surgical site. Temp 99.9 here
Physical Exam
General Appearance
pt obvious in discomfort with swelling over r jaw and neck, dressing in place, alert, oriented x 3
Skin
R neck with 1 cm open incision and suture line about 3 cm below R ear, swollen , not erythemic, ttp. small amount of serosaguinous drainage on dressing
Eyes
PERRL, sub conjunctival hemmorhage in sclera L eye medially, FEOM , +RR, unable to visualize discs
Ears
NL canals, TMs clear with normal landmarks
Nose
NL shape, dried scab in r nare
Mouth
diff to asses due to pain opening mouth
Neck
supple, tender over r side around surgical site, rotates head slowly at request, 3 cm odd shaped erythemic ? abrsion over post l side of neck
Heart
RRR, no murmur, S1 & S2
Lungs
Clear to auscultation, no rales or wheezes, sat 97
Abdomen
Soft, non-tender, no masses. Liver/spleen not enlarged. NL bowel sounds.
Neurological
Non- focal neuro exam with cranial nerves 2-12 grossly intact, difficulty raising shoulders d/t apin in neck, pt has difficulty standing upright for rhomberg,motor tone is normal and symetric, Patellar reflexes are 1-2+,Babinski is negative and gait appears unsteady. No tics or tremors noted. No nystagmus seen. Alert & oriented x 3
Assessment and Plan
Assesment
s/p multiple trauma
r/o sub dural hematoma
R mandible fx with surgery 7/11 at BI deaconess
Plan:
changed neck dressing, explained to mom , who will get tape at pharmacy to change daily
monitor for fever q4 , call BMC page operator at 617-638-8000 and page oral/max surgeon if develops fever or go to BMC or BI ER
mom to call neuro surg 617-632-7246 for f/u appt per instructions, she has d/c note with detailed instructions for f/u and meds. all explained to uncle in english, translated for mom
I WOULD APRRECIATE ANY INPUT TO USE CORRECT ICD9 THANKS
- Note - Outpatient - - Notes Module
Header
Chief Complaint
seen at Lawrence General ER 7/9 after being jumped by several people,transfered to Beth Israel,told concussion, c/o nausea today with red streak down rt side of face
Vital Signs
AGE 17y9.7m
TEMPERATURE 99.9 F
BLOOD PRESSURE 120/70
WEIGHT 119.6 lb
WEIGHT (%) 8
History of Present Illness
17 yo M seen at Law general ER 3 days ago after being beaten up by several youth, transferred to BI deaconess with r/o sub dural hematoma and R mandibular fx. Had jaw surgery 7/11, seen by neuro with no focal sx and d/c to home 7/12. On oxycodone 1-2 tabs q3 for pain, keflex 500 mg q6, colace and levetiracetam 500mg BID through 7/16.
Spanish speaking mom and english speaking uncle here with patient today for redness on back of neck. Mom told to have him seen if neck turns red near surgical site. Temp 99.9 here
Physical Exam
General Appearance
pt obvious in discomfort with swelling over r jaw and neck, dressing in place, alert, oriented x 3
Skin
R neck with 1 cm open incision and suture line about 3 cm below R ear, swollen , not erythemic, ttp. small amount of serosaguinous drainage on dressing
Eyes
PERRL, sub conjunctival hemmorhage in sclera L eye medially, FEOM , +RR, unable to visualize discs
Ears
NL canals, TMs clear with normal landmarks
Nose
NL shape, dried scab in r nare
Mouth
diff to asses due to pain opening mouth
Neck
supple, tender over r side around surgical site, rotates head slowly at request, 3 cm odd shaped erythemic ? abrsion over post l side of neck
Heart
RRR, no murmur, S1 & S2
Lungs
Clear to auscultation, no rales or wheezes, sat 97
Abdomen
Soft, non-tender, no masses. Liver/spleen not enlarged. NL bowel sounds.
Neurological
Non- focal neuro exam with cranial nerves 2-12 grossly intact, difficulty raising shoulders d/t apin in neck, pt has difficulty standing upright for rhomberg,motor tone is normal and symetric, Patellar reflexes are 1-2+,Babinski is negative and gait appears unsteady. No tics or tremors noted. No nystagmus seen. Alert & oriented x 3
Assessment and Plan
Assesment
s/p multiple trauma
r/o sub dural hematoma
R mandible fx with surgery 7/11 at BI deaconess
Plan:
changed neck dressing, explained to mom , who will get tape at pharmacy to change daily
monitor for fever q4 , call BMC page operator at 617-638-8000 and page oral/max surgeon if develops fever or go to BMC or BI ER
mom to call neuro surg 617-632-7246 for f/u appt per instructions, she has d/c note with detailed instructions for f/u and meds. all explained to uncle in english, translated for mom
I WOULD APRRECIATE ANY INPUT TO USE CORRECT ICD9 THANKS