Clinic Progress Note Question & Answer Guide (With Explanation)

This type of question evaluates analytical and critical thinking skills.

What This Question Is About

This question relates to clinic progress note and requires a structured academic response.

How to Approach This Question

Use appropriate theories and support your answer with clear reasoning.

Key Explanation

This topic involves clinic progress note. A strong answer should include explanation, application, and examples.

Original Question

Clinic Progress Note, Sore Throat Report both the E/M and lab service. A hint for looking up the strep screen in the CPT index is that it is a bacterial culture. LOCATION: Outpatient, Clinic PATIENT: Leah Charles PHYSICIAN: Rita Wimer, MD SUBJECTIVE: The patient is a 31/2-year-old girl who was seen by me 4 months ago, and today presents with her parents to the clinic. Her mother states that both her brother and sister have been on medication for the second time because of being positive for strep. The patient started complaining of a sore throat 2 days ago. She is also complaining of some ear pain. She does have an ALLERGY to SULFA. Mother noticed a rash on the side of her lips just the other day. OBJECTIVE: On general appearance, the patient is alert. She does not appear to be in acute distress. Temperature is 99.9˚ F. Weight is 13.6 kg (kilogram). HEENT (head, ears, eyes, nose, throat): Both TMs (tympanic membranes) are clear. Her PE (pressure equalization) tube is out in the canal on the left. Oropharynx is erythematous. Also, along her lip she does have some erythematous lesions with golden crust and consistent with impetigo. Neck has shotty (like a pellet) cervical nodes bilaterally but is supple. Heart reveals a regular rate and rhythm without murmur. Lungs are clear to auscultation bilaterally. Her abdomen is soft. IMPRESSION: 1. Pharyngitis, rule out strep 2. Impetigo PLAN: 1. Keflex 250 mg (milligram)/5 cc (cubic centimeter) 3/4 teaspoon orally, three times daily × 10 days. 2. We will also do a strep screen as well, today. SERVICE CODE(S): ______________________________________ ICD-10-CM DX CODE(S): ____________________

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