Here is the notes and it is a new patient. Would this be 99204? And why? Thank you!!!!!
Current Medications
None
Past Medical History
Healthy infancy, toddler & preschool years - viruses, occ OM
Possible small amount of asthma last year, allergy symptoms this year
Frequent infections 2013, all year
Surgical History
Denies Past Surgical History
Family History
Father: alive
Mother: alive
Maternal Grand Father: alive
Maternal Grand Mother: unknown
Paternal Grand Father: alive
Paternal Grand Mother: alive
Siblings: Lupus - older
2 brother(s) , 3 sister(s) .
No FH of depression or bipolar illness, or other psychiatric disorders.
Social History
Smoking (13yrs and up) Status: Never.
Lives With: Parents.
Language: English.
Country of Birth: U.S.
Pediatric Home safety measures: has smoke detector.
Tobacco Exposure: Yes.
Animal Exposures: dogs.
Allergies
N.K.D.A.
Hospitalization/Major Diagnostic Procedure
Denies Past Hospitalization
Review of Systems
CC basic:
Brought by mother.
Reason for Appointment
1. New pt/Physical
History of Present Illness
Sick:
15 year old female presents with c/o concerns about multiple symptoms -- She sleeps too much, has body aches & low energy. c/o Headache which is mild, all over her head, and almost daily. c/o Feeding less - eats when she is hungry, then stops eating early, saying that she is full.
Denies : Rhinorrhea. COUGH. Fever. Sore Throat. Vomiting. Diarrhea. Abdominal pain.
Pediatric Mood :
Parents primary concern: Her eating disorder. She is in therapy, has some anxiety. Mother brought Kiara in because she is still very tired, losing hair, & has headaches almost daily (generalized). Symptoms began abruptly when in November or December of last year. Kiara has improved a lot since starting counseling. The counselor said that Kiara's physical symptoms should be evaluated. Parental report on General Mood: improving since therapy. Before, she moody and evasive, withdrawn, pulling away with emotions appeared sad, & irritable. No w she is doing better. Interaction with parents: Helping at home a little better since starting counseling. Patient's report on General Mood still likes to be alone in her room, doesn't like to be gone to much, passes up things that she used to like to do.. Anxiety symptoms: has anxiety at times - she worries and over-thinks things. Anxiety makes her pull back. School issues: started out strong, then started missing a lot. Grade 9. SLEEPING: sometimes can't sleep or wakes up at night and can't sleep for 30 to 60 minutes. Other concerns: Has lost 25 pounds in a 2 month period.
Vital Signs
Pain scale 0, Wt 106.2 lbs, Ht 62.01 in, BMI Percentile 39.52, BMI 19.42, BP 97/60, Temp 98.0, HR 109, L M P 7/2014, SaO2 97, Ht Percentile 23.13, Wt Percentile 27.4, VA-L 20/30, VA-R 20/30, VA-Both 20/30.
Examination
CC Pediatric Exam:
GENERAL APPEARANCE: well nourished, serious young woman with good eye contact, who is cooperative and pleasant, and appropriately groomed, but does have a sad expression most of the visit and has muted affect and a quiet voice. SKIN: no rashes, no skin lesions. HEAD: normocephalic. EYES: normal, sclera/conjunctiva clear. EARS: TMs: pearly gray, with good light reflection. NOSE: nares patent and clear, mucosa normal. ORAL CAVITY: moist mucous membranes, tonsils normal, pharynx without erythema or exudate. NECK: supple, no lymphadenopathy. HEART: RRR, no murmurs. LUNGS: clear, equal breath sounds bilaterally. ABDOMEN: soft, nontender, no masses. EXTREMITIES: moving all extremities equally. NEUROLOGIC EXAM: non-focal. OTHER Impressions from patient's drawing of a tree, house and person:, (provided by a volunteer psychologist who was provided only the patient's gender and age). Picture has a central house with a long, wide path coming from the door, which ends in a blackened circle. The house is flanked by a small tree in the background and a cloud. The cloud is blackened and there is a similar dark patch as the leaves of the tree. The picture suggests that she may have suffered trauma, perhaps even severe trauma or sexual abuse, and could be at risk of suicide. The picture conveys a lot of depression, and raises concern that she is at risk of dissociation, as she forgot to draw the person in the picture. As a coping strategy, she may become obsessive. (The obsessiveness shows in the trees canopy, which is made of dozens of tiny, interlocking concentric circles). There is no person in the picture, as stated above.
Assessments
1. Fatigue - 780.79 (Primary)
2. Dizziness - 780.4
3. Vaccine refusal by caregiver - V64.05, refused HPV. Mother got tense and emphatically refused this vaccine because it was 'new'.
Treatment
1. Fatigue
LAB: CBC With Differential/Platelet Anaya,Elsy 07/15/2014 05:35:52 PM > sent to lab.
LAB: Complete Metabolic Panel Na 148, CO2 16, remainder normal Calcium, Serum 9.8 8.9-10.4 - mg/dL
Glucose, Serum 105 H 65-99 - mg/dL
BUN 12 5-18 - mg/dL
Protein, Total, Serum 7.6 6.0-8.5 - g/dL
Albumin, Serum 4.9 3.5-5.5 - g/dL
Bilirubin, Total 0.2 0.0-1.2 - mg/dL
Alkaline Phosphatase, S 68 54-121 - IU/L
AST (SGOT) 17 0-40 - IU/L
Potassium, Serum 4.1 3.5-5.2 - mmol/L
Sodium, Serum 148 H 134-144 - mmol/L
Chloride, Serum 108 97-108 - mmol/L
Creatinine, Serum 0.73 0.57-1.00 - mg/dL
ALT (SGPT) 8 0-24 - IU/L
Carbon Dioxide, Total 16 L 18-29 - mmol/L
BUN/Creatinine Ratio 16 9-25 -
Globulin, Total 2.7 1.5-4.5 - g/dL
A/G Ratio 1.8 1.1-2.5 -
eGFR If NonAfricn Am UNABL1 - mL/min/1.73
eGFR If Africn Am UNABL1 - mL/min/1.73
LAB: Free T4 (Thyroxine) 1.10 T4,Free(Direct) 1.10 0.93-1.60 - ng/dL
LAB: TSH Normal, 0.863 TSH 0.863 0.450-4.500 - uIU/mL
LAB: Ferritin, Serum Normal, 33 Request Problem CLOT9 -
Ferritin, Serum 33 15-77 - ng/mL
LAB: Sedimentation Rate-Westergren 2 Sedimentation Rate-Westergren 2 0-32 - mm/hr
LAB: Zinc, Whole Blood Normal, 662 Zinc, Whole Blood 662 440-860 - ug/dL
Preventive Medicine
CC sick: F/u for new symptoms, poor oral intake, increased crying or pain, difficulty breathing, high fevers, weakness, changes, or if worse.
.
Face to face time with patient was 45-50 mintues. At that point, patient needed blood tests, and we wanted them to be drawn in time to go out with the evening pick-up, and it was ~5:10 or 5:15. I had a patient waiting who was a (quick) follow-up appointment. I told mother that we would draw patient's blood, and then I would come back in and discuss the screening forms and the plan. I returned ~ 5 minutes after the blood draw was completed (per my MA), but was told the patient's mother left immediately after the blood draw, stating that I could call her back, but she culdn't wait. She was here 1 hour 40 minutes total, with 45 minutes check-in time to being seen by me, 45-50 minutes face to face with me, and ~ 10 minutes for the blood draw.
Current Medications
None
Past Medical History
Healthy infancy, toddler & preschool years - viruses, occ OM
Possible small amount of asthma last year, allergy symptoms this year
Frequent infections 2013, all year
Surgical History
Denies Past Surgical History
Family History
Father: alive
Mother: alive
Maternal Grand Father: alive
Maternal Grand Mother: unknown
Paternal Grand Father: alive
Paternal Grand Mother: alive
Siblings: Lupus - older
2 brother(s) , 3 sister(s) .
No FH of depression or bipolar illness, or other psychiatric disorders.
Social History
Smoking (13yrs and up) Status: Never.
Lives With: Parents.
Language: English.
Country of Birth: U.S.
Pediatric Home safety measures: has smoke detector.
Tobacco Exposure: Yes.
Animal Exposures: dogs.
Allergies
N.K.D.A.
Hospitalization/Major Diagnostic Procedure
Denies Past Hospitalization
Review of Systems
CC basic:
Brought by mother.
Reason for Appointment
1. New pt/Physical
History of Present Illness
Sick:
15 year old female presents with c/o concerns about multiple symptoms -- She sleeps too much, has body aches & low energy. c/o Headache which is mild, all over her head, and almost daily. c/o Feeding less - eats when she is hungry, then stops eating early, saying that she is full.
Denies : Rhinorrhea. COUGH. Fever. Sore Throat. Vomiting. Diarrhea. Abdominal pain.
Pediatric Mood :
Parents primary concern: Her eating disorder. She is in therapy, has some anxiety. Mother brought Kiara in because she is still very tired, losing hair, & has headaches almost daily (generalized). Symptoms began abruptly when in November or December of last year. Kiara has improved a lot since starting counseling. The counselor said that Kiara's physical symptoms should be evaluated. Parental report on General Mood: improving since therapy. Before, she moody and evasive, withdrawn, pulling away with emotions appeared sad, & irritable. No w she is doing better. Interaction with parents: Helping at home a little better since starting counseling. Patient's report on General Mood still likes to be alone in her room, doesn't like to be gone to much, passes up things that she used to like to do.. Anxiety symptoms: has anxiety at times - she worries and over-thinks things. Anxiety makes her pull back. School issues: started out strong, then started missing a lot. Grade 9. SLEEPING: sometimes can't sleep or wakes up at night and can't sleep for 30 to 60 minutes. Other concerns: Has lost 25 pounds in a 2 month period.
Vital Signs
Pain scale 0, Wt 106.2 lbs, Ht 62.01 in, BMI Percentile 39.52, BMI 19.42, BP 97/60, Temp 98.0, HR 109, L M P 7/2014, SaO2 97, Ht Percentile 23.13, Wt Percentile 27.4, VA-L 20/30, VA-R 20/30, VA-Both 20/30.
Examination
CC Pediatric Exam:
GENERAL APPEARANCE: well nourished, serious young woman with good eye contact, who is cooperative and pleasant, and appropriately groomed, but does have a sad expression most of the visit and has muted affect and a quiet voice. SKIN: no rashes, no skin lesions. HEAD: normocephalic. EYES: normal, sclera/conjunctiva clear. EARS: TMs: pearly gray, with good light reflection. NOSE: nares patent and clear, mucosa normal. ORAL CAVITY: moist mucous membranes, tonsils normal, pharynx without erythema or exudate. NECK: supple, no lymphadenopathy. HEART: RRR, no murmurs. LUNGS: clear, equal breath sounds bilaterally. ABDOMEN: soft, nontender, no masses. EXTREMITIES: moving all extremities equally. NEUROLOGIC EXAM: non-focal. OTHER Impressions from patient's drawing of a tree, house and person:, (provided by a volunteer psychologist who was provided only the patient's gender and age). Picture has a central house with a long, wide path coming from the door, which ends in a blackened circle. The house is flanked by a small tree in the background and a cloud. The cloud is blackened and there is a similar dark patch as the leaves of the tree. The picture suggests that she may have suffered trauma, perhaps even severe trauma or sexual abuse, and could be at risk of suicide. The picture conveys a lot of depression, and raises concern that she is at risk of dissociation, as she forgot to draw the person in the picture. As a coping strategy, she may become obsessive. (The obsessiveness shows in the trees canopy, which is made of dozens of tiny, interlocking concentric circles). There is no person in the picture, as stated above.
Assessments
1. Fatigue - 780.79 (Primary)
2. Dizziness - 780.4
3. Vaccine refusal by caregiver - V64.05, refused HPV. Mother got tense and emphatically refused this vaccine because it was 'new'.
Treatment
1. Fatigue
LAB: CBC With Differential/Platelet Anaya,Elsy 07/15/2014 05:35:52 PM > sent to lab.
LAB: Complete Metabolic Panel Na 148, CO2 16, remainder normal Calcium, Serum 9.8 8.9-10.4 - mg/dL
Glucose, Serum 105 H 65-99 - mg/dL
BUN 12 5-18 - mg/dL
Protein, Total, Serum 7.6 6.0-8.5 - g/dL
Albumin, Serum 4.9 3.5-5.5 - g/dL
Bilirubin, Total 0.2 0.0-1.2 - mg/dL
Alkaline Phosphatase, S 68 54-121 - IU/L
AST (SGOT) 17 0-40 - IU/L
Potassium, Serum 4.1 3.5-5.2 - mmol/L
Sodium, Serum 148 H 134-144 - mmol/L
Chloride, Serum 108 97-108 - mmol/L
Creatinine, Serum 0.73 0.57-1.00 - mg/dL
ALT (SGPT) 8 0-24 - IU/L
Carbon Dioxide, Total 16 L 18-29 - mmol/L
BUN/Creatinine Ratio 16 9-25 -
Globulin, Total 2.7 1.5-4.5 - g/dL
A/G Ratio 1.8 1.1-2.5 -
eGFR If NonAfricn Am UNABL1 - mL/min/1.73
eGFR If Africn Am UNABL1 - mL/min/1.73
LAB: Free T4 (Thyroxine) 1.10 T4,Free(Direct) 1.10 0.93-1.60 - ng/dL
LAB: TSH Normal, 0.863 TSH 0.863 0.450-4.500 - uIU/mL
LAB: Ferritin, Serum Normal, 33 Request Problem CLOT9 -
Ferritin, Serum 33 15-77 - ng/mL
LAB: Sedimentation Rate-Westergren 2 Sedimentation Rate-Westergren 2 0-32 - mm/hr
LAB: Zinc, Whole Blood Normal, 662 Zinc, Whole Blood 662 440-860 - ug/dL
Preventive Medicine
CC sick: F/u for new symptoms, poor oral intake, increased crying or pain, difficulty breathing, high fevers, weakness, changes, or if worse.
.
Face to face time with patient was 45-50 mintues. At that point, patient needed blood tests, and we wanted them to be drawn in time to go out with the evening pick-up, and it was ~5:10 or 5:15. I had a patient waiting who was a (quick) follow-up appointment. I told mother that we would draw patient's blood, and then I would come back in and discuss the screening forms and the plan. I returned ~ 5 minutes after the blood draw was completed (per my MA), but was told the patient's mother left immediately after the blood draw, stating that I could call her back, but she culdn't wait. She was here 1 hour 40 minutes total, with 45 minutes check-in time to being seen by me, 45-50 minutes face to face with me, and ~ 10 minutes for the blood draw.
