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Evaluation and Management Case 008
History HPI: 9 Yrs 2 Mos female established patient who presents to the office with compliants of throat pain and neck pain since yesterday afternoon. Better with motrin (12.5ml, last dose at 0630 this morning). Worse with sitting down or laying down. No abdominal pain. Has slight headache at base of head. No new rashes (follows with dermatology for eczema, given a cream last week when seen by dermatologist). No "fevers" but forehead feels "a bit hot" now. Decreased oral intake of solids but is doing well with liquids. Normal UOP. No known ill contacts but attends school. No trauma to neck but says base of neck hurts with flexion and extension of neck. Past Medical History: Past Medical History: UNSPECIFIED ASTHMA Eczema, followed by dermatology. Otherwise healthy. Past Surgical History: None. Allergies: No Known Allergies Immunizations: Immunizations Up to Date: Yes Medications: Motrin as needed for pain, albuterol as needed, no other medicines (stopped singulair and flovent about 6 months). Family History: No ill contacts Cardiac/Sudden Death: negative Diabetes: positive: grandparents, extended family members Asthma: negative Hematologic: not obtained/not obtainable Genetic: not obtained/not obtainable Social History: LAHW parents and sibs. Daycare or School: yes Smokers: no Review of Systems: Constitutional: HPI Eyes: negative ENT/Mouth: HPI CV: negative Respiratory: negative All others reviewed and are negative |
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