1. Apply diagnosis/procedure codes according to current guidelines (Bloom’s Level 3)Classification SystemsICD (ICD-9-CM, ICD-10, ICD-10-CM/PCS)TaxonomiesClinical Care Classification (CCC)NomenclaturesCPT, DSM, RxNormTerminologiesLOINC,

  

1. Apply diagnosis/procedure codes according to current guidelines (Bloom’s Level 3)Classification SystemsICD (ICD-9-CM, ICD-10, ICD-10-CM/PCS)TaxonomiesClinical Care Classification (CCC)NomenclaturesCPT, DSM, RxNormTerminologiesLOINC, SNOMED CT Emergency Department Patient Case Number: ED22-Dorman, Sonja Patient Name: Sonja Dorman DOB: 02-14-00 Sex: F Date of Service: 07-17-XX Attending Physician: Sandra Gillman, MD Reason for Visit: Head injury History of Present Illness: Miss Dorman presents to the Emergency Department after having a head injury at a football game. She was in the bleachers performing the wave. She threw her hands in the air and her feet came out from under her. She struck her head on the back of the bleachers. She reports feeling fine at this time no neck pain. She has a small abrasion to the posterior scalp but no need for repair. She denies any nausea vomiting denies any dizziness denies any headache denies any fatigue. She has no other complaints. Medical History: Factor V Leiden mutation Medications: Warfarin Review of Systems: Constitutional: Negative for diaphoresis, fatigue and fever. HENT: Negative for congestion, ear pain, nosebleeds and sore throat. Eyes: Negative for photophobia, pain, discharge and visual disturbance. Respiratory: Negative for cough, choking, chest tightness, shortness of breath and wheezing. Cardiovascular: Negative for chest pain and palpitations. Gastrointestinal: Negative for abdominal distention, abdominal pain, diarrhea and vomiting. Genitourinary: Negative for dysuria, flank pain and frequency. Musculoskeletal: Negative for back pain, gait problem and joint swelling. Skin: Negative for color change and rash. Neurological: Negative for dizziness, syncope and headaches. Psychiatric/Behavioral: Negative for behavioral problems and confusion. The patient is not nervous/anxious. All other systems reviewed and are negative. Vitals: Temperature 98.9°F Pulse 98 Respirations 20 Blood Pressure 138/70 SpO2 99% 6/2/2021 ED22DormanSonja https://myahima.brightspace.com/content/enforced/6681-VLAB_STUDENTPROTO/PatientCaseScenarios/Emergency_Department/ED22DormanSonj… 2/3 Physical Examination Constitutional: She is oriented to person, place, and time. She appears well-developed and well-nourished. She is cooperative. Non-toxic appearance. She does not have a sickly appearance. She does not appear ill. No distress. HEENT Head: Normocephalic and atraumatic. Right Ear: Tympanic membrane and external ear normal. Left Ear: Tympanic membrane and external ear normal. Nose: No rhinorrhea, sinus tenderness or nasal deformity. No epistaxis. Right sinus exhibits no maxillary sinus tenderness and no frontal sinus tenderness. Left sinus exhibits no maxillary sinus tenderness and no frontal sinus tenderness. Mouth/Throat: Oropharynx is clear and moist and mucous membranes are normal. Normal dentition. Eyes: EOM are normal. Pupils are equal, round, and reactive to light. Neck: Normal range of motion. Neck supple. Cardiovascular: Normal rate, regular rhythm and normal heart sounds. No murmur heard. Pulmonary/Chest: Effort normal and breath sounds normal. No accessory muscle usage. No respiratory distress. She has no wheezes. She has no rales. She exhibits no tenderness. Abdominal: Soft. She exhibits no distension. There is no guarding. Musculoskeletal: Normal range of motion. She exhibits no edema or tenderness. Lymphadenopathy: She has no cervical adenopathy. Neurological: She is alert and oriented to person, place, and time. She exhibits normal muscle tone. Skin: Skin is warm and dry. No rash noted. No erythema. Psychiatric: She has a normal mood and affect. Medical Decision Making Concussion without loss of consciousness, initial encounter: new and requires workup Minor head injury, initial encounter: new and requires workup Diagnosis management : No LOC, no CT at this time. Verbal instructions given in addition to reasons to return to the department. Final Diagnosis: 1) Concussion without loss of consciousness, initial encounter 2) Abrasion to posterior scalp, initial encounter 3) Factor V Leiden mutation Discharge Prescriptions: Zofran 4mg, Sig: Take one tablet by mouth every 8 hours as needed for nausea or vomiting for up to three days Electronically Signed By: Sandra Gillman, M Health Science Science Nursing HS 292 Share (0)