AAPC - Chapter 20 Practical Applications
CASE 1 10-Year-old established patient (The patient is established.) presents today for well child check (Patient presents for a preventive exam.) with mother with complaints of frequent urination during the day. The patient has two sisters and sees dad sporadically. Lives in a smoke free environment. One dog, one rabbit. Denies dysuria, abdominal pain, or rashes, all other systems are reviewed and negative. Patient going into 4th grade with good grades. No parental concerns. Patient cooperates but does tend to back talk. Doing well on Concerta Exam General: Normal Head: Normal Eyes: Normal Ears: Normal Nose: Normal Mouth/throat: Normal Neck: Normal Abdomen: Normal Rectal: Not examined Genitals: Normal Skin: 3mm papule on dorsal R hand without disruption of creases Urinalysis: Ketones, nitrite, leukocytes normal; trace blood, low specific gravity. (Urinalysis lab test performed in the office) Counseled patient on the use of seat belts, bicycle/skate helmets, gun safety, water/sun safety. Assessment: Well Child Check, ADHD, Wart, Frequent Urination (Preventive exam and problems treated.) Refill Concerta 18mg PO q AM Wart cleansed with alcohol. Histofreeze x 25 seconds (Wart is destroyed.) was performed to destroy the wart. Varicella Vaccine #2 (Vaccination is administered.) administered without any complications.
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