OUTPATIENT ICD-9 AND ICD-10-CM CODING

Medical Specialty: ENT - Otolaryngology

Chronic hypertrophic adenotonsillitis – Adenotonsillectomy

Description:

Adenotonsillectomy, primary, patient under age 12.

PREOPERATIVE DIAGNOSIS:

Chronic hypertrophic adenotonsillitis.

POSTOPERATIVE DIAGNOSIS:

Chronic hypertrophic adenotonsillitis.

OPERATIVE PROCEDURE:

Adenotonsillectomy, primary, patient under age 12.

ANESTHESIA:

General endotracheal anesthesia.

PROCEDURE IN DETAIL:

This patient was brought from the holding area and did receive preoperative antibiotics of Cleocin as well as IV Decadron. She was placed supine on the operating room table. General endotracheal anesthesia was induced without difficulty. In the holding area, her allergies were reviewed. It is unclear whether she is actually allergic to penicillin. Codeine caused her to be excitable, but she did not actually have an allergic reaction to codeine. She might be allergic to BACTRIM and SULFA. After positioning a small shoulder roll and draping sterilely, McIvor mouthgag, #3 blade was inserted and suspended from the Mayo stand. There was no bifid uvula or submucous cleft. She had 3+ cryptic tonsils with significant debris in the tonsillar crypts. Injection at each peritonsillar area with 0.25% with Marcaine with 1:200,000 Epinephrine, approximately 1.5 mL total volume. The left superior tonsillar pole was then grasped with curved Allis forceps. _______ incision and dissection in the tonsillar capsule and hemostasis and removal of the tonsil was obtained with Coblation Evac Xtra Wand on 7/3. Mouthgag was released, reopened, no bleeding was seen. The right tonsil was then removed in the same fashion. The mouthgag released, reopened, and no bleeding was seen. Small red rubber catheter in the nasal passage was used to retract the soft palate. She had mild-to-moderate adenoidal tissue residual. It was removed with Coblation Evac Xtra gently curved Wand on 9/5. Red rubber catheter was then removed. Mouthgag was again released, reopened, no bleeding was seen. Orogastric suction carried out with only scant clear stomach contents. Mouthgag was then removed. Teeth and lips were inspected and were in their preoperative condition. The patient then awakened, extubated, and taken to recovery room in good condition.

TOTAL BLOOD LOSS FROM TONSILLECTOMY:

Less than 2 mL.

TOTAL BLOOD LOSS FROM ADENOIDECTOMY:

Less than 2 mL.

COMPLICATIONS:

No intraoperative events or complications occurred.

PLAN:

Family will be counseled postoperatively. Postoperatively, the patient will be on Zithromax oral suspension 500 mg daily for 5 to 7 days, Lortab Elixir for pain. Promethazine if needed for nausea and vomiting.

  • 474.00, 474.01; J35.01, J35.02; 42821
  • 474.02; J35.03; 42825, 42830
  • 474.10; J35.3; 42820
  • 474.11, 474.2; J35.8; 42860

Answer

Labyrinthitis

Description:

Dizziness, nausea, and vomiting

HISTORY:

This patient developed an acute onset of dizziness, nausea, and vomiting a few months ago and was seen in the Emergency Room and was diagnosed as having inner-ear viral involvement. This happened in May. Since then, she has been suffering from occasional imbalance and dizzy spells, particularly when she bends down and gets up. She takes medicine for control of hypertension.

On Exam:

The right eardrum is normal. The left eardrum has an atrophic tympanic membrane on the posterior half of the drum surface. There is no sign of middle-ear effusion. Nose and throat examination was normal. Audiogram demonstrated bilateral sensorineural hearing loss, somewhat worse in the left ear. Tympanogram was normal. Speech reception thresholds were 20 dB in the left ear and 10 dB in the right ear.

Clinically, there is no spontaneous or positional nystagmus. Her gait and stance with eyes closed were quite normal. There is no cerebellar sign.

I suspect the patient is just recovering from a bout of viral labyrinthitis which struck her in May this year, and she still has some residual balance problem. I expect a further recovery in the very near future. There is no need to pursue further investigations.

Diagnosis:

Resolving viral labyrinthitis, left ear.

  • 386.35; H83.02
  • 780.4; R42
  • 386.33; H83.09M
  • 386.31; H83.09

Answer

Consult - Pulsatile Tinnitus

Description:

Chronic headaches and pulsatile tinnitus.

HISTORY:

The patient is a 48 year-old female who was seen in consultation requested from Dr. X on 05/28/2008 regarding chronic headaches and pulsatile tinnitus. The patient reports she has been having daily headaches since 02/25/2008. She has been getting pulsations in the head with heartbeat sounds. Headaches are now averaging about three times per week. They are generally on the very top of the head according to the patient. Interestingly, she denies any previous significant history of headaches prior to this. There has been no nausea associated with the headaches. The patient does note that when she speaks on the phone, the left ear has "weird sounds." She feels a general fullness in the left ear. She does note pulsation sounds within that left ear only. This began on February 17th according to the patient. The patient reports that the ear pulsations began following an air flight to Iowa where she was visiting family. The patient does admit that the pulsations in the ears seem to be somewhat better over the past few weeks. Interestingly, there has been no significant drop or change in her hearing. She does report she has had dizzy episodes in the past with nausea, being off balance at times. It is not associated with the pulsations in the ear. She does admit the pulsations will tend to come and go and there had been periods where the pulsations have completely cleared in the ear. She is denying any vision changes. The headaches are listed as moderate to severe in intensity on average about three to four times per week. She has been taking Tylenol and Excedrin to try to control the headaches and that seems to be helping somewhat. The patient presents today for further workup, evaluation, and treatment of the above-listed symptoms.

REVIEW OF SYSTEMS:

ALLERGY/IMMUNOLOGIC:

Negative.

CARDIOVASCULAR:

Hypercholesterolemia.

PULMONARY:

Negative.

GASTROINTESTINAL:

Pertinent for nausea.

GENITOURINARY:

The patient is noted to be a living kidney donor and has only one kidney.

NEUROLOGIC:

History of dizziness and the headaches as listed above.

VISUAL:

Negative.

DERMATOLOGIC:

History of itching. She has also had a previous history of skin cancer on the arm and back.

ENDOCRINE:

Negative.

MUSCULOSKELETAL:

Negative.

CONSTITUTIONAL:

She has had an increased weight gain and fatigue over the past year.

PAST SURGICAL HISTORY:

She has had a left nephrectomy, C-sections, mastoidectomy, laparoscopy, and T&A.

FAMILY HISTORY:

Father, history of cancer, hypertension, and heart disease.

CURRENT MEDICATIONS:

Tylenol, Excedrin, and she is on multivitamin and probiotic's.

ALLERGIES:

She is allergic to codeine and penicillin.

SOCIAL HISTORY:

She is married. She works at Eye Center as a receptionist. She denies tobacco at this time though she was a previous smoker, stopped four years ago, and she denies alcohol use.

PHYSICAL EXAMINATION:

VITAL SIGNS:

Blood pressure 120/78, pulse 64 and regular, and the temperature is 97.4.

GENERAL:

The patient is an alert, cooperative, well-developed 48 year-old female with a normal-sounding voice and good memory.

HEAD & FACE:

Inspected with no scars, lesions or masses noted. Sinuses palpated and are normal. Salivary glands also palpated and are normal with no masses noted. The patient also has full facial function.

CARDIOVASCULAR:

Heart regular rate and rhythm without murmur.

RESPIRATORY:

Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.

EYES:

Extraocular muscles were tested and within normal limits.

EARS:

There is an old mastoidectomy scar, left ear. The ear canals are clean and dry. Drums intact and mobile. Weber exam is midline. Grossly hearing is intact. Please note audiologist not available at today's visit for further audiologic evaluation.

NASAL:

Reveals clear drainage. Deviated nasal septum to the left, listed as mild to moderate. Ostiomeatal complexes are patent and turbinates are healthy. There was no mass or neoplasm within the nasopharynx noted on fiberoptic nasopharyngoscopy. See fiberoptic nasopharyngoscopy separate exam. ORAL: Oral cavity is normal with good moisture. Lips, teeth and gums are normal. Evaluation of the oropharynx reveals normal mucosa, normal palates, and posterior oropharynx. Examination of the larynx with a mirror reveals normal epiglottis, false and true vocal cords with good mobility of the cords. The nasopharynx was briefly examined by mirror with normal appearing mucosa, posterior choanae and eustachian tubes.

NECK:

The neck was examined with normal appearance. Trachea in the midline. The thyroid was normal, nontender, with no palpable masses or adenopathy noted.

NEUROLOGIC:

Cranial nerves II through XII evaluated and noted to be normal. Patient oriented times 3.

DERMATOLOGIC:

Evaluation reveals no masses or lesions. Skin turgor is normal.

IMPRESSION:

  • Pulsatile tinnitus, left ear with eustachian tube disorder as the etiology. Consider, also normal pressure hydrocephalus.
  • Recurrent headaches.
  • Deviated nasal septum.
  • Dizziness, again also consider possible Meniere disease.

RECOMMENDATIONS:

I did recommend the patient begin a 2 g or less sodium diet. I have also ordered a carotid ultrasound study as part of the workup and evaluation. She has had a recent CAT scan of the brain though this was without contrast. It did reveal previous mastoidectomy, left temporal bone, but no other mass noted. I have started her on Nasacort AQ nasal spray one spray each nostril daily as this is eustachian tube related. Hearing protection devices should be used at all times as well. I did counsel the patient if she has any upcoming airplane trips to use nasal decongestant or topical nasal decongestant spray prior to boarding the plane, and also using the airplane ear plugs as these can be effective at helping to prevent eustachian tube issues. I am going to recheck her in three weeks. If the pulsatile tinnitus at that time is not clear, we have discussed other treatment options including myringotomy or ear tube placement, which could be done here in the office. She will be scheduled for a audio and tympanogram to be done as well prior to that procedure.

  • 388.31, 388.9, 471.1; H93.19, H93.92, J33.1
  • 388.30, 381.9, 784.0, 470, 780.4; H93.12, H69.92, R51, J34.2, R42
  • 388.30, 381.9, 478.0; H93.13, H69.92, J34.3
  • 386.00, 784.0, 780.4; H81.02, R51, R42

Answer

Hearing loss

This patient was seen regarding evaluation of hearing loss. Hearing allegedly is generally reduced in both ears, but he has always, throughout his entire life, had worse hearing in his left ear, presumably subsequent to childhood otorrhea which he does recall.

Examination:

Revealed an intact right tympanic membrane. He has a relatively small posterosuperior perforation of the left drum which unfortunately overlies the stapes incus and to a slight degree, the round window. He also has a bit of otomycosis infection involving the proximal ear canal, although no evident involvement of the middle ear.

Lab:

Audiometry shows a mild to moderately-severe bilateral nerve deafness of symmetric degree with a substantial additional conductive deafness in his left ear due to the perforation. Speech levels averaged approximately 35-40 dB in the right ear and about 80 dB in the left ear.

Diagnoses:

  • Mild to moderately-severe bilateral sensorineural hearing loss.
  • Perforated left tympanic membrane with moderate conductive deafness.
  • Otomycosis, left ear canal.

Plan:

The ear was cleaned and I have applied a Canesten ointment to the entire canal and will follow-up in a month. His option is either to use a hearing aid in the left and/or both ears to get better hearing, or to undergo tympanoplasty surgery to his left ear to close the perforation. He can then see how he feels about his hearing loss, of which the sensorineural component will remain, to see whether subsequent hearing aids are still needed. He will give me his decision on these options when he returns for a recheck of his otomycosis.

  • 389.10, 384.24, 388.60; H90.5, H72.819, H92.12
  • 389.21, 384.00, 386.33; H90.71, H73.003, H83.02
  • 389.8, 384.25, 380.10; H91.03, H72.822, H60.02
  • 389.20, 384.20, 111.9; H90.8, H72.92, B36.9

Answer

Ear pain with drainage

Description:

Right ear pain with drainage - otitis media and otorrhea.

CHIEF COMPLAINT:

Right ear pain with drainage.

HISTORY OF PRESENT ILLNESS:

This is a 12 year-old white male here with his mother for complaints of his right ear hurting. Mother states he has been complaining for several days. A couple of days ago she noticed drainage from the right ear. The patient states it has been draining for several days and it has a foul smell to it. He has had some low-grade fever. The patient was seen in the office about a week ago with complaints of a sore throat, headache and fever. The patient was evaluated for Strep throat which was negative and just had been doing supportive care. He did have a recent airplane ride a couple of weeks ago also. There has been no cough, shortness of breath or wheezing. No vomiting or diarrhea.

PHYSICAL EXAM:

General:

He is alert in no distress.

Vital Signs:

Temperature: 99.1 degrees.

HEENT:

Normocephalic, atraumatic. Pupils equal, round and react to light. The left TM is clear. The right TM is poorly visualized secondary to purulent secretions in the right ear canal. There is no erythema of the ear canals. Nares is patent. Oropharynx is clear. The patient does wear braces.

Neck:

Supple.

Lungs:

Clear to auscultation.

Heart:

Regular. No murmur.

ASSESSMENT:

  • Right otitis media.
  • Right otorrhea.

PLAN:

Ceftin 250 mg by mouth twice a day for 10 days. Ciprodex four drops to the right ear twice a day. The patient is to return to the office in two weeks for followup.

  • 382.00, 388.69; H66.007, H92.21
  • 382.01, 388.70; H66.017, H92.01
  • 382.9, 388.60; H66.91, H92.11
  • 382.9, 388.69; H66.93, H92.20

Answer

Exudative tonsillitis

Description:

Severe tonsillitis, palatal cellulitis, and inability to swallow.

CHIEF COMPLAINT:

Severe tonsillitis, palatal cellulitis, and inability to swallow.

HISTORY OF PRESENT ILLNESS:

This patient started having sore throat approximately one week ago; however, yesterday it became much worse. He was unable to swallow. He complained to his parent. He was taken to Med Care and did not get any better, and therefore presented this morning to ER, where seen and evaluated by Dr. X and concerned as whether he had an abscess either pharyngeal, palatal, or peritonsillar. He was noted to have extreme tonsillitis with kissing tonsils, marked exudates especially right side and right palatal cellulitis. A CT scan at ER did not show abscess. He has not had airway compromise, but he has had difficulty swallowing. He may have had a low-grade fever, but nothing marked at home. His records from Hospital are reviewed as well as the pediatric notes by Dr. X. He did have some equivalent leukocytosis. He had a negative monospot and negative strep screen.

PAST MEDICAL HISTORY:

The patient takes no medications, has had no illnesses or surgeries and he is generally in good health other than being significantly overweight. He is a sophomore at High School.

FAMILY HISTORY:

Noncontributory to this illness.

SURGERIES:

None.

HABITS:

Nonsmoker, nondrinker. Denies illicit drug use.

REVIEW OF SYSTEMS:

ENT:

The patient other than having dysphagia, the patient denies other associated ENT symptomatology.

GU:

Denies dysuria.

Orthopedic:

Denies joint pain, difficulty walking, etc.

Neuro:

Denies headache, blurry vision, etc.

Eyes:

Says vision is intact.

Lungs:

Denies shortness of breath, cough, etc.

Skin:

He states he has a rash, which occurred from penicillin that he was given IM yesterday at Covington Med Care. Mildly itchy. Mother has penicillin allergy.

Endocrine:

The patient denies any weight loss, weight gain, skin changes, fatigue, etc, essentially no symptoms of hyper or hypothyroidism.

Physical Exam:

General:

This is a morbidly obese male adolescent, in no acute disease, alert and oriented x 4. Voice is normal. He is handling his secretions. There is no stridor.

Vital Signs:

See vital signs in nurses notes.

Ears:

TM and EACs are normal. External, normal.

Nose:

Opening clear. External nose is normal.

Mouth:

Has bilateral marked exudates, tonsillitis, right greater than left. Uvula is midline. Tonsils are touching. There is some redness of the right palatal area, but is not consistent with peritonsillar abscess. Tongue is normal. Dentition intact. No mucosal lesions other than as noted.

Neck:

No thyromegaly, masses, or adenopathy except for some small minimally enlarged high jugular nodes.

Chest:

Clear to auscultation.

Heart:

No murmurs, rubs, or gallops.

Abdomen:

Obese. Complete exam deferred.

Skin:

Visualized skin dry and intact, except for rash on his inner thighs and upper legs, which is red maculopapular and consistent with possible allergic reaction.

Neuro:

Cranial nerves II through XII are intact. Eyes, pupils are equal, round, and reactive to light and accommodation, full range.

IMPRESSION:

Marked exudative tonsillitis, non-strep, non-mono, probably mixed anaerobic infection. No significant prior history of tonsillitis. Possible rash to PENICILLIN.

RECOMMENDATIONS:

I concur with IV clindamycin and IV Solu-Medrol as per Dr. X. I anticipate this patient may need several days of IV antibiotics and then be able to switch over to oral. I do not insist that this patient will need surgical intervention since there is no evidence of abscess. This one episode of severe tonsillitis does not mean the patient needs tonsillectomy, but if he continues to have significant tonsil problems after this he should be referred for ENT evaluation as an outpatient. The patient's parents in the room had expressed good understanding, have a chance to ask questions. At this time, I will see the patient back on an as needed basis.

  • 464.50, 528.09, 787.29; J04.30, K12.1, R13.19
  • 462, 528.2, 787.20; J02.9, K12.0, R13.10
  • 474.02, 478.19, 787.21; J35.03, J34.9, R13.11
  • 463, 528.3, 787.20; J03.90, K12.2, R13.0

Answer

Auricular abscess - I&D

Description:

Incision and drainage with bolster dressing placement of right ear recurrent auricular abscess.

PREOPERATIVE DIAGNOSIS:

Recurrent severe right auricular abscess.

POSTOPERATIVE DIAGNOSIS:

Recurrent severe right auricular abscess.

TITLE OF PROCEDURE:

Incision and drainage with bolster dressing placement of right ear recurrent auricular abscess.

ANESTHESIA:

Xylocaine 1% with 1:100,000 dilution of epinephrine totaling 2 mL.

COMPLICATIONS:

None.

FINDINGS:

Approximately 5 mL of serosanguineous drainage.

PROCEDURE:

The patient underwent an incision and drainage procedure with stay suture placement on 05/28/2008 by me for a large auricular abscess. She presents for suture removal; however, there is still fluid noted now at the antihelix fold above the concha bullosa. It was recommended that this area be drained through the previous incision and drainage incision which has healed and wound care by the patient appears to be very poor if any at all being performed which may be complicating matters. Consent was obtained. The patient is aware that the complications with this ear area severe and auricular deformity is inevitable; however, quick prompt aggressive drainage addressing fluid collections offers a best chance for improvement from an already very difficult situation.

The area was prepped in the usual manner, localized and the previous incision was reopened with a curved hemostat and about 5 mL of serosanguineous drainage was noted. A through-and-through Keith needle bolster dressing was applied with cottonoid pledget on both sides of the ear to help compression. She tolerated this procedure very well.

  • 380.10; H60.321; 69140
  • 380.10; H60.01; 69000
  • 380.14; H60.21; 69110
  • 380.12; H60.331; 69020

Answer

Bilateral chronic serous otitis media - Myringotomy/tube insertion

Description:

Bilateral myringotomies and insertion of Shepard grommet draining tubes.

PREOPERATIVE DIAGNOSIS:

Bilateral chronic serous otitis media.

POSTOPERATIVE DIAGNOSIS:

Bilateral chronic serous otitis media.

OPERATION PERFORMED:

  • Bilateral myringotomies.
  • Insertion of Shepard grommet draining tubes.

ANESTHESIA:

General, by mask.

ESTIMATED BLOOD LOSS:

Less than 1 mL.

COMPLICATIONS:

None.

FINDINGS:

The patient had a long history of persistent recurrent infections and was placed on antibiotics for the same. At this point in time, he had a small amount of thick mucoid material in both middle ear spaces with middle ear mucosa somewhat inflamed, but no active acute infection at this point in time.

PROCEDURE:

With the patient under adequate general anesthesia with the mask delivery of anesthesia, he had his ear canals cleaned utilizing an operating microscope and all foul cerumen had been removed from both sides. Bilateral inferior radial myringotomies were performed, first on the right and then on the left. Middle ear spaces were suctioned of small amount of thick mucoid material on both sides and then Shepard grommet draining tubes were inserted on either side. Floxin drops were then instilled bilaterally to decrease any clotting within the tubes, and then cotton ball was placed in the external meatus bilaterally. At this point, the patient was awakened and returned to the recovery room, satisfactory, with no difficulty encountered.

  • 381.20; H65.33; 69433-50
  • 381.00; H65.193; 69436
  • 381.10; H65.23; 69436-50
  • 381.19; H65.23; 69421, 69433-51

Answer

Recurrent nasal obstruction

Description:

Patient with suspected nasal obstruction, possible sleep apnea.

CHIEF COMPLAINT:

Recurrent nasal obstruction.

HISTORY OF PRESENT ILLNESS:

The patient is a 5 year-old male, who was last evaluated by Dr. F approximately one year ago for suspected nasal obstruction, possible sleep apnea. Dr. F's assessment at that time was the patient not had sleep apnea and did not truly even seem to have allergic rhinitis. All of his symptoms had resolved when he had seen Dr. F, so no surgical plan was made and no further followup was needed. However, the patient reports again today with his mother that they are now having continued symptoms of nasal obstruction and questionable sleep changes. Again, the mother gives a very confusing sleep history but it does not truly sound like the child is having apneic events that are obstructive in nature. It sounds like he is snoring loudly and does have some nasal obstruction at nighttime. He also is sniffing a lot through his nose. He has been tried on some nasal steroids but they only use this on a p.r.n. basis about one or two days every month and we are unsure if that has even helped at all, probably not. The child is not having any problems with his ears including ear infections or hearing. He is also not having any problems with strep throat.

PAST MEDICAL HISTORY:

Eczema.

PAST SURGICAL HISTORY:

None.

MEDICATIONS:

None.

ALLERGIES:

No known drug allergies.

FAMILY HISTORY:

No family history of bleeding diathesis or anesthesia difficulties.

PHYSICAL EXAMINATION:

VITAL SIGNS:

Weight 43 pounds, height 37 inches, temperature 97.4, pulse 65, and blood pressure 104/48.

GENERAL:

The patient is a well-nourished male in no acute distress. Listening to his voice today in the clinic, he does not sound to have a hyponasal voice and has a wide range of consonant pronunciation.

NOSE:

Anterior rhinoscopy does demonstrate boggy turbinates bilaterally with minimal amount of watery rhinorrhea.

EARS:

The patient tympanic membranes are clear and intact bilaterally. There is no middle ear effusion.

ORAL CAVITY:

The patient has 2+ tonsils bilaterally. There are clearly nonobstructive. His uvula is midline.

NECK:

No lymphadenopathy appreciated.

ASSESSMENT AND PLAN:

This is a 5 year-old male, who presents for repeat evaluation of a possible nasal obstruction, questionable sleep apnea. Again, the mother gives a confusing sleep history but it does not really sound like he is having apneic events. They deny any actual gasping events. It sounds like true obstructive events. He clearly has some symptoms at this point that would suggest possible allergic rhinitis or chronic rhinitis. I think the most appropriate way to proceed would be to first try this child on a nasal corticosteroid and use it appropriately. I have given them prescription for Nasacort Aqua one spray to each nostril twice a day. I instructed them on correct way to use this and the importance to use it on a daily basis. They may not see any benefit for several weeks. I would like to evaluate him in six weeks to see how we are progressing. If he continues to have problems, I think at that point we may consider performing a transnasal exam in the office to examine his adenoid bed and that would really be the only surgical option for this child. He may also need an allergy evaluation at that point if he continues to have problems. However, I would like to be fairly conservative in this child. Should the mother still have concerns regarding his sleeping at our next visit or should his symptoms worsen (I did instruct her call us if it worsens), we may even need to pursue a sleep study just to settle that issue once and for all. We will see him back in six weeks.

  • 478.19, 786.09; J34.89, R06.83
  • 470, 786.09; J34.2, R06.3
  • 478.0, 786.2; J34.3, R05
  • 478.19, 786.03; J34.9, R06.81

Answer

Acute maxillary sinusitis

Description:

Patient with postnasal drainage, sore throat, facial pain, coughing, headaches, congestion, nasal burning and teeth pain.

CHIEF COMPLAINT:

Sinus problems.

SINUSITIS HISTORY:

The problem began 2 weeks ago and is constant. Symptoms include postnasal drainage, sore throat, facial pain, coughing, headaches and congestion. Additional symptoms include nasal burning and teeth pain. The symptoms are characterized as moderate to severe. Symptoms are worse in the evening and morning.

REVIEW OF SYSTEMS:

ROS General:

General health is good.

ROS ENT:

As noted in history of present Illness listed above.

ROS Respiratory:

Patient denies any respiratory complaints, such as cough, shortness of breath, chest pain, wheezing, hemoptysis, etc.

ROS Gastrointestinal:

Patient denies any nausea, vomiting, abdominal pain, dysphagia or any altered bowel movements.

ROS Respiratory:

Complaints include coughing.

ROS Neurological:

Patient complains of headaches. All other systems are negative.

PAST SURGICAL HISTORY:

Gallbladder 7/82. Hernia 5/79

PAST MEDICAL HISTORY:

Negative.

PAST SOCIAL HISTORY:

Marital Status: Married. Denies the use of alcohol. Patient has a history of smoking 1 pack of cigarettes per day and for the past 15 years. There are no animals inside the home.

FAMILY MEDICAL HISTORY:

Family history of allergies and hypertension.

CURRENT MEDICATIONS:

Claritin. Dilantin.

PREVIOUS MEDICATIONS UTILIZED:

Rhinocort Nasal Spray.

EXAM:

Exam Ear:

Auricles/external auditory canals reveal no significant abnormalities bilaterally. TMs intact with no middle ear effusion and are mobile to insufflation.

Exam Nose:

Intranasal exam reveals moderate congestion and purulent mucus.

Exam Oropharynx:

Examination of the teeth/alveolar ridges reveals missing molars. Examination of the posterior pharynx reveals a prominent uvula and purulent postnasal drainage. The palatine tonsils are 2+ and cryptic.

Exam Neck:

Palpation of anterior neck reveals no tenderness. Examination of the posterior neck reveals mild tenderness to palpation of the suboccipital muscles.

Exam Facial:

There is bilateral maxillary sinus tenderness to palpation.

X-RAY / LAB FINDINGS:

Water's view x-ray reveals bilateral maxillary mucosal thickening.

IMPRESSION:

Acute maxillary sinusitis.

MEDICATION:

Augmentin. 875 mg bid. MucoFen 800 mg bid.

PLAN:

Will get mini sinus CT if no improvement.

FOLLOW-UP:

The patient was instructed to return in 2-3 weeks or sooner if necessary.

  • 461.0, 305.1; J01.01, R06.89, F17.200
  • 461.8, V15.82; J01.40, Z87.891
  • 461.8, V15.82; J01.41, Z87.891
  • 461.0, 305.1; J01.00, F17.200

Answer