Peds New OV#1 x
This is a 4 yo child who was brought in by mom for the first time with a history of eczema (Chief complaint) that has been acting up. According to mom, she did have eczema previously, but at this point, parent is seeing more rashes on her legs(HPI location), abdomen, as well as the upper extremity. The patient also has been (HPI Assoc S&S) itching. According to mom, apart from the eczema, she does not have any history of bronchial asthma or nasal allergies.(Past History) Other than that, there were no other concerns.
Past History: according to mom, she has been a healthy child. No hospitalizations. She has had an emergency room visit for abrasion of the scalp. (PFSH Past History)
Allergies: None to medications. (PFSH Past History)
HISTORY = Brief HPI (2) + No ROS + PFSH (1 area) = Problem Focused History
Examination: 95 Exam 97 GMS Exam
Constitutional On examination, active, alert child. Weight is 16.9 kg. She is not in any visible distress. (1 bullet: appearance)
ENT Ears: TMs are clear, bilateral. Nose: No active rhinorrhea seen. Oropharynx: Moist and clear. (3 bullets: ex TM, ext insp nose, ex oropharynx)
Neck (BA) Neck is supple. (1 bullet: ex neck)
Respiratory Chest: Good air exchange, bilateral. Clear breath sounds. No wheezing, rales, or rhonchi. (1 bullet: ausc lungs)
Cardiovascular Heart: S1, S2 plus. Regular rate and rhythm. No murmur. (1 bullet: ausc heart)
Gastrointestinal Abdomen is soft, nontender. No organomegaly. Peristaltic sounds present. (2 bullets: ex abdomen, ex liver and spleen)
Integumentary Examination of the skin reveals skin colored fine popular lesions seen, which are also scaly. Some of them on the lower extremities are hyperpigmented. Few lesions are seen on the abdomen, which are also more scaly. The antecubital fossa does not reveal many lesions, but the elbow as well as knee area has skin colored follicles, which are prominent. No other type of lesions seen. (1 bullet: insp skin)
CMS 95 Exam 6 systems 1 BA (skin in detail) = Detailed exam
WPS 95 Exam 6 systems 1 BA = Detailed exam
1997 GMS Exam 10 bullets = Expanded Problem Focused Exam
Diagnosis: Generalized mild atopic dermatitis.
Plan: At this point, mom is advised to keep her less time in water, mild soap, to use a moisturizer throughout the body. She was also given 2.5% hydrocortisone cream to be used in the areas that are affected. I feel that the symptoms should subside. Eczema being a chronic condition, it can recur. Meanwhile, mom is advised to make an appointment early for a complete physical as well as updating the shots. Parent agrees.
MDM:
# Dx and Management Options: New Problem to examiner no work up (3 pts Multiple)
Data Review: 0 pts Minimal
Risk: Prescription Drug Management Moderate
MDM: Multiple 3 pts + Minimal Data Review 0 pts + Moderate Risk = Moderate MDM
Problem Focused History + Detailed Exam + Moderate MDM = 99201
ICD 9 Coding 1. Atopic Dermatitis 691.8