Patient initial and age: C.M., 2 years old Gender: Male Race: White
DATE OF SERVICE: October 14, 2013
Chief Complaint: Per mom- "My child has been very fussy since around noon today which is not like him, she states he is a really happy baby.” She states “she was trying very hard to treat him herself because she thought it was just a little common cold and runny nose from being at day care all week.” She also stated “she had been treating him herself with liquid Tylenol all day Friday and then his temperature went up on Saturday morning to 101.0 so she decided to bring him in for treatment.”
History of Present illness: Per mother, patient is currently going to day care during the week and she bought him home on Friday with a runny nose and
Past Medical History:
Allergies: NKDA
Medical History: No medical history
Surgeries: None
Vaccinations: Mother states “she does not know specific dates of vaccines but states all immunizations are up to date.”
Medication List:
NKDA
Family History:
Mother-Tonsillectomy, Appendectomy
Father- No history
Social History: Full time in day care.
Review Of System: (The information given per mother, patient sleeping throughout the exam)
Constitutional- Mother states he has fever, no chills, or weight loss
Head/Eyes- Mother states does have drainage from eyes. Mother denies any pain or itching to bilateral eyes. Patient does not use eye glasses.
ENMT- Mother states he has had recent nose drainage but no bleeds, sinus congestion, post nasal drainage or reports of sore throat.
Cardiovascular- Mother denies any unusual shortness of breath with age appropriate activities. No recent complaints of chest pain.
Respiratory- Mother denies any known cough, congestion, or hemoptysis.
Gastrointestinal- Negative for abdominal pain and nausea/vomiting. Mother denies any appetite loss, denies any known constipation, diarrhea, flatulence, heartburn. Last stated bowel movement was this morning.
Genitourinary- Mother denies any known discharge or complaints of penile pain. States he has been urinating normal, no difficulties.
Musculoskeletal- Denies any recent injury or fall. Denies any known deficits in age appropriate activities.
Integumentary- Mother denies any recent skin complaints including rashes, abnormal moles, dry skin, or irritation.
Neurological- Mother denies any complaints of headache. Has noted no gait abnormalities or recent falls.
Psychiatric- Mother states no known history of depression and participates appropriately for age in all activities.
Endocrine- Mother denies any polyphagia or polydipsia. Weight appropriate for age. Fatigue at this time due to just not feeling good, she states.
Hematologic/Lymphatic- Mother denies any increase bruising or history of anemia.
Allergic/Immunologic- Mother denies any known exposure to bodily fluids or seasonal allergies.
Objective Data:
Physical Exam:
Constitutional- Well nourished, well developed for age. Temp: 100.2, HR 96, RR 22, O2 sat 100% on room air. No blood pressure measured. Weight: 19.0kg
Head/Eyes- Normocephalic, PERRL, Conjunctiva clear with no drainage noted.
ENMT- TM normal on left ear and bulging on right ear, no exudation noted in left but right with exudation in ear canal, nasal passages clear, no gross oropharyngeal lesions, oral mucosa wet, no adenopathy noted.
Cardiovascular- regular rate, capillary refill < 3sec. No gallop or murmur noted.
Respiratory- Breath sounds clear and equal bilaterally. Equal chest rise and fall.
Gastrointestinal- Bowel sounds heard in all four quadrants. Soft, no tenderness or distention noted upon palpation. Patient negative for rebound tenderness. Negative for murphy's sign, rovsing's sign or tenderness at McBurney's point. Abdominal series completed and showed normal bowel gas pattern and no acute disease in chest or abdomen.
Genitourinary- No urinalysis done due to exam not warranted. Musculoskeletal- Patient demonstrates full range of motion with no signs of pain.
Integumentary- General skin overview reveals no significant rash or other lesion
Neurological- Alert and appropriate for age. No signs of focal motor or sensory deficit.
Psychiatric- Patient's reactions are appropriate for age.
Hematologic/Lymphatic/Immunologic- No outward signs of bleeding, vital signs do not indicate severe anemia. Fatigue appropriate for child due to not feeling well.
Assessment/Analysis:
CPT- 99203 (new patient-with detailed focused assessment)
Problem List:
Otitis Media (382.9)and Removal of cerumen with child spoon (69210)- Physical exam warrants to otitis media of the right ear. Left ear is free and clear of cerumen.
Plan:
Goals for primary diagnosis of Otitis Media:
Short term goal: Complete course of antibiotics to resolve Otitis Media. Mother admits that father smokes and he sometimes smokes in house and around baby.
Long term goal: Implementation of tips how to avoid Otitis Media. If baby is around cigarette smoking there is strong evidence that this causes babies to have otitis media and being in day care also
Intervention:
1. Complete course of Corticosteroid. Prescription given for Prednisolone-Prelone 15mg/5ml oral suspension. 3ml PO BID for seven days. Dispense 70ml with no refills.
Medicine is available at target and walmart as a part of their $4 generic list program
If filled at publix, generic will be given free of charge (promoted to patient's mother)
Education is key here. Mother educated on promoting good wiping technique and avoidance of bubble baths. Also told to avoid soaps with strong fragrances. Mother educated to encourage water and to promote frequent urination breaks in the future.
As far as diet- promoted bland diet for 24 hours and then advanced as tolerated. Told to avoid spicy foods as well as heavy foods with dairy products. Promoted use of Gatorade.
Evaluation:
Patient to follow-up with pediatrician care provider in one week after finishing antibiotics. Told to return if patient begins to complain of back pain, increasing urinary symptoms, or fever.
DATE OF SERVICE: October 14, 2013
Chief Complaint: Per mom- "My child has been very fussy since around noon today which is not like him, she states he is a really happy baby.” She states “she was trying very hard to treat him herself because she thought it was just a little common cold and runny nose from being at day care all week.” She also stated “she had been treating him herself with liquid Tylenol all day Friday and then his temperature went up on Saturday morning to 101.0 so she decided to bring him in for treatment.”
History of Present illness: Per mother, patient is currently going to day care during the week and she bought him home on Friday with a runny nose and
Past Medical History:
Allergies: NKDA
Medical History: No medical history
Surgeries: None
Vaccinations: Mother states “she does not know specific dates of vaccines but states all immunizations are up to date.”
Medication List:
NKDA
Family History:
Mother-Tonsillectomy, Appendectomy
Father- No history
Social History: Full time in day care.
Review Of System: (The information given per mother, patient sleeping throughout the exam)
Constitutional- Mother states he has fever, no chills, or weight loss
Head/Eyes- Mother states does have drainage from eyes. Mother denies any pain or itching to bilateral eyes. Patient does not use eye glasses.
ENMT- Mother states he has had recent nose drainage but no bleeds, sinus congestion, post nasal drainage or reports of sore throat.
Cardiovascular- Mother denies any unusual shortness of breath with age appropriate activities. No recent complaints of chest pain.
Respiratory- Mother denies any known cough, congestion, or hemoptysis.
Gastrointestinal- Negative for abdominal pain and nausea/vomiting. Mother denies any appetite loss, denies any known constipation, diarrhea, flatulence, heartburn. Last stated bowel movement was this morning.
Genitourinary- Mother denies any known discharge or complaints of penile pain. States he has been urinating normal, no difficulties.
Musculoskeletal- Denies any recent injury or fall. Denies any known deficits in age appropriate activities.
Integumentary- Mother denies any recent skin complaints including rashes, abnormal moles, dry skin, or irritation.
Neurological- Mother denies any complaints of headache. Has noted no gait abnormalities or recent falls.
Psychiatric- Mother states no known history of depression and participates appropriately for age in all activities.
Endocrine- Mother denies any polyphagia or polydipsia. Weight appropriate for age. Fatigue at this time due to just not feeling good, she states.
Hematologic/Lymphatic- Mother denies any increase bruising or history of anemia.
Allergic/Immunologic- Mother denies any known exposure to bodily fluids or seasonal allergies.
Objective Data:
Physical Exam:
Constitutional- Well nourished, well developed for age. Temp: 100.2, HR 96, RR 22, O2 sat 100% on room air. No blood pressure measured. Weight: 19.0kg
Head/Eyes- Normocephalic, PERRL, Conjunctiva clear with no drainage noted.
ENMT- TM normal on left ear and bulging on right ear, no exudation noted in left but right with exudation in ear canal, nasal passages clear, no gross oropharyngeal lesions, oral mucosa wet, no adenopathy noted.
Cardiovascular- regular rate, capillary refill < 3sec. No gallop or murmur noted.
Respiratory- Breath sounds clear and equal bilaterally. Equal chest rise and fall.
Gastrointestinal- Bowel sounds heard in all four quadrants. Soft, no tenderness or distention noted upon palpation. Patient negative for rebound tenderness. Negative for murphy's sign, rovsing's sign or tenderness at McBurney's point. Abdominal series completed and showed normal bowel gas pattern and no acute disease in chest or abdomen.
Genitourinary- No urinalysis done due to exam not warranted. Musculoskeletal- Patient demonstrates full range of motion with no signs of pain.
Integumentary- General skin overview reveals no significant rash or other lesion
Neurological- Alert and appropriate for age. No signs of focal motor or sensory deficit.
Psychiatric- Patient's reactions are appropriate for age.
Hematologic/Lymphatic/Immunologic- No outward signs of bleeding, vital signs do not indicate severe anemia. Fatigue appropriate for child due to not feeling well.
Assessment/Analysis:
CPT- 99203 (new patient-with detailed focused assessment)
Problem List:
Otitis Media (382.9)and Removal of cerumen with child spoon (69210)- Physical exam warrants to otitis media of the right ear. Left ear is free and clear of cerumen.
Plan:
Goals for primary diagnosis of Otitis Media:
Short term goal: Complete course of antibiotics to resolve Otitis Media. Mother admits that father smokes and he sometimes smokes in house and around baby.
Long term goal: Implementation of tips how to avoid Otitis Media. If baby is around cigarette smoking there is strong evidence that this causes babies to have otitis media and being in day care also
Intervention:
1. Complete course of Corticosteroid. Prescription given for Prednisolone-Prelone 15mg/5ml oral suspension. 3ml PO BID for seven days. Dispense 70ml with no refills.
Medicine is available at target and walmart as a part of their $4 generic list program
If filled at publix, generic will be given free of charge (promoted to patient's mother)
Education is key here. Mother educated on promoting good wiping technique and avoidance of bubble baths. Also told to avoid soaps with strong fragrances. Mother educated to encourage water and to promote frequent urination breaks in the future.
As far as diet- promoted bland diet for 24 hours and then advanced as tolerated. Told to avoid spicy foods as well as heavy foods with dairy products. Promoted use of Gatorade.
Evaluation:
Patient to follow-up with pediatrician care provider in one week after finishing antibiotics. Told to return if patient begins to complain of back pain, increasing urinary symptoms, or fever.