A new patient comes in with a chief complaint of a sore throat. The throat has been
Question:
A new patient comes in with a chief complaint of a sore throat. The throat has been sore for 4 days. It has been getting worse over time. No fever or chills. A brother has been diagnosed with strep in the past week.
Exam:
Vitals: Temp: 101.2, pulse 40, BP: 100/70.
ENT: Oropharynx is swollen and red. External ears are normal. Tympanic membranes are normal. Nasal mucosa looks normal. Cervical lymph nodes are swollen and tender.
ABD: Nontender and no masses.
Eyes: Pupils equal and reactive.
Rapid strep negative but did a strep culture given exam and family member currently having strep throat.
Impression:Sore throat, possible strep throat. Will await culture results. Since patient's family is homeless and doesn't have a phone, the mother will get in touch with us in 3 days to get culture results Over the counter medications for the sore throat. If throat gets worse patient is to return.
Assign the appropriate E&M and diagnosis codes for this scenario.