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Diag suggestions

  1. #1
    Question Diag suggestions
    Exam Training Packages
    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

  2. #2
    Post
    V54.19.
    Girish Dadhich, CPC

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