jifnif
Expert
I have a visit that I am questioning the level. could someone help me with this report? Our dr is saying it is Moderate Complexity and I have it as Low.
Impression
-
Lupus psychosis
Lupus
Seizure d/o
HTN
Plan
-
her behaviour makes me suspect more of supratentorial issues then purely lupus given spoke to rheum yestrerday and today withdrawn and every nsg attempt in vain
will d/w penn foundation possible admission to their unit
did recieve mirtazapine but her demeneour is more suspicious of pschosis then med effect
consultants appreciated
rheum w/u pending but N ESR favours against any acute processes
Subjective
-
resting in bed sleeping and withdraws to touch bit will not talk,make eye contact or arouse
Physical Examination
General Appearance: No Apparent Distress
Cardiovascular: Regular Rate/Rhythm
Lungs: Clear Auscult./Percussion
Abdomen: Soft, Non-Tender, Bowel Sounds Active
Neuro: - (resting,withdrawn,avoids eye contact and any attempts to converse)
Clinical Data
-
Labs: All labs have been reviewed in the EMR.
Impression
-
Lupus psychosis
Lupus
Seizure d/o
HTN
Plan
-
her behaviour makes me suspect more of supratentorial issues then purely lupus given spoke to rheum yestrerday and today withdrawn and every nsg attempt in vain
will d/w penn foundation possible admission to their unit
did recieve mirtazapine but her demeneour is more suspicious of pschosis then med effect
consultants appreciated
rheum w/u pending but N ESR favours against any acute processes
Subjective
-
resting in bed sleeping and withdraws to touch bit will not talk,make eye contact or arouse
Physical Examination
General Appearance: No Apparent Distress
Cardiovascular: Regular Rate/Rhythm
Lungs: Clear Auscult./Percussion
Abdomen: Soft, Non-Tender, Bowel Sounds Active
Neuro: - (resting,withdrawn,avoids eye contact and any attempts to converse)
Clinical Data
-
Labs: All labs have been reviewed in the EMR.