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?? 99214

  1. #1
    Question ?? 99214
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    CC:from school c/o dizzy, jaw pain, "feels gross" BP standing 100/58 P 88 sitting 104/58 P 66 lying down BP 98/60 P 64

    Vital Signs
    AGE 16y10.8m
    PULSE 88
    WEIGHT 118.8 lb
    WEIGHT (%) 45

    History of Present Illness
    lightheaded yesterday at staples when getting out of the car. woke up this morning not feeling well, c/o jaw pain. b/l posterior jaw pain, no trauma noted. pain radiates to back of the head at times 3-4x today--felt like muscles squeezing in the back of her head, lasted for 25seconds. light-headed all day. went to school RN, laid down for a little. went home early, took a nap. pain 6/10 in jaw, max 7-8/10, min 0/10.
    --feeling nauseated in waves, no vomiting/diarrhea. abd pain with nausea like upset stomach. a little RLQ pain yesterday but resolved on its own, didn't think much of it
    --yogurt earlier today, nothing to drink today except a couple sips of water. needs a note if ok to have waterbottle at school. tends to get lightheaded during illness--see also 3/10 notes when dehydrated with post-concussive syndrome, postural hypotn
    --no fevers, nasal sxs, coughing, throat pain (? a little), ear pain on left earlier but went away quickly
    --no known sick contacts.
    --was supposed to take tylenol earlier but didn't
    meds: adderall, lamictal, ocp--no recent changes

    Interval History
    Specialty appointment since last visit? Y
    8/17 had right lumpectomy with dr jones--came back negative
    Physical Exam
    General Appearance
    No cyanosis, rash, abnl pigmented lesions, normal skin turgor and capillary refill
    Normocephalic, atraumatic, except anterior lower jaw with slight symmetric fullness, no bruising noted but +ttp.
    perrl, eomi, glasses
    NL canals, TMs clear with normal landmarks
    NL shape, no discharge
    NL tongue, mucosa, dentition. no TMJ ttp. swelling or pain at stensons duct or salivary glands under tongue b/l, even with milking
    NL tonsils. No petechiae, exudate
    Supple, no adenopathy or masses
    RRR, no murmur, S1 & S2. hr 85 after sitting for awhile
    Clear to auscultation, no rales or wheezes
    s/nd, mild ttp RLQ with deep palpation, no r/g (c/w pain last night that had since gone away and doesn't hurt once i stop pressing). +bs. no hsm
    Assessment and Plan
    16yr female with nausea, mild sym jaw swelling, lightheadedness.
    --doubt parotiditis as no fever, swelling more anteriorly located than over parotid
    --not clear gum lesions, teeth all wnl
    --push fluids in small freq amounts, ok for gingerale/gatorade to help with nausea/lightheadness respectively. goal for 1liter over next 2hrs at home
    --start motrin with fluids/food for next few days until pain/swelling improves
    --dsicussed liberal use of salt in diet, importance of staying well-hydrated, esp when sick
    --if no better in next few days, t/c dental or oral surgery consultation, sooner if worsening
    --note for school and note to allow h20 bottle in schoolAcknowledge/Ok Acknowledge/Next Error Enlarge
    HistoryCC ListE-mailE-mail HistoryCl.MessageEditAddendumCopyError Approve

  2. #2
    This is a 99214 to me.

    Laura, CPC, CPMA, CEMC

  3. #3
    Nashville, Tennessee
    I agree Laura.
    The amount of history obtained and exam performed is up to clinical judgment in order to diagnose and treat a patient.

    Hx: HPI with 4 elements, ROS >2 but <9, and pertinent medical history (at least current meds and/or reference to previous visit = Detailed History (limited by system inventory)
    Exam: 8 OS/BA = Comprehensive Exam

    The nature of the problem may be self-limited/minor/transient; we don't know because it's not defined. There was no "diagnosis", only ill-defined symptoms for a new problem with no work-up, and the managements were minimal. Still, a Detailed History + Comprehensive Exam = 99214.


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