View MR 099405

MR 099405

CC: Shortness of breath

HPI: 16-year-old female comes into the ED for shortness of breath for the last two days. She is an asthmatic.

Current medications being used to treat symptoms is Advair, which is not working and breathing is getting worse. Does not feel that Advair has been helping. Patient tried Albuterol for persistent coughing, is not helping. Coughing 10-15 minutes at a time. Patient has used the Albuterol 3x in the last 16 hrs. ED physician admits her to observation status.

ROS: No fever, no headache. No purulent discharge from the eyes. No earache. No nasal discharge or sore throat. No swollen glands in the neck. No palpitations. Dyspnea and cough. Some chest pain. No nausea or vomiting. No abdominal pain, diarrhea, or constipation.

PMH: Asthma

SH: Lives with both parents.

FH: Family hx of asthma, paternal side

ALLERGIES: PCN-200 CAPS. Allergies have been reviewed with child’s family and no changes reported.

PE: General appearance: normal, alert. Talks in sentences. Pink lips and cheeks. Oriented. Well developed. Well nourished. Well hydrated.

Eyes: normal. External eye: no hyperemia of the conjunctiva. No discharge from the conjunctiva

Ears: general/bilateral. TM: normal. Nose: rhinorrhea. Pharynx/Oropharynx: normal. Neck: normal.

Lymph nodes: normal.

Lungs: before Albuterol neb, mode air entry b/l. No rales, rhonchi or wheezes. After Albuterol neb. improvement of air entry b/l. Respiratory movements were normal. No intercostals inspiratory retraction was observed.

Cardiovascular system: normal. Heart rate and rhythm normal. Heart sounds normal. No murmurs were heard.

GI: abdomen normal with no tenderness or masses. Normal bowel sounds. No hepatosplenomegaly

Skin: normal warm and dry. Pink well perfused

Musculoskeletal system patient indicates lower to mid back pain when she lies down on her back and when she rolls over. No CVA tenderness.

Assessment: Asthma, acute exacerbation

Plan: Will keep her in observation overnight. Will administer oral steroids and breathing treatment. CXR ordered and to be taken in the morning.

What E/M code is reported?