Blake Photo Time-Line

ONLC PEDIATRICS OCHSNER, BATON ROUGE REGION LA

Grondin, Blake John MRN: 12051461, DOB: 2/14/2020, Sex: M

Acct #: 72015178898 Enc. Date 12/16/2021

12/16/2021 - Office Visit in O'Neal - Pediatrics

Reason for Visit Cough Fever

Nasal Congestion

Sick since Monday with CCC. Started with fever yesterday. Playful and active. Will drink well, not eating as much. Ear drainage also.

Diagnoses

Codes

Comments

Bronchiolitis - Primary

ICD-10-CM: J21.9 ICD-9-CM: 466.19 ICD-10-CM: H66.006 ICD-9-CM: 382.00

Recurrent acute suppurative otitis media without spontaneous rupture of tympanic membrane of both sides

Problem List as of 12/16/2021

Date Reviewed: 12/16/2021

Codes

Priority

Class

Noted - Resolved

Newborn affected by maternal use of other drugs of addiction

ICD-10-CM: P04.49 ICD-9-CM: 760.79

2/14/2020 - Present

Overview Addendum 2/14/2020 2:04 PM by Myriam Ortiz-de Jesus, MD

Polysubstance drug exposure during pregnancy. Infant UDS + for opioids. Buprenorphine screen and meconium screen pending. Infant at high risk for withdrawal and this was explained to mom as well as the need for observation for a minimum of 72 hrs. Mother verbalized understanding. Mom may breast feed infant. Plans: NAS every 3 hrs, SS consult.

Mother's group B Streptococcus colonization status unknown

ICD-10-CM: IMO0002 ICD-9-CM: IMO0002

2/14/2020 - Present

Overview Signed 2/14/2020 2:03 PM by Myriam Ortiz-de Jesus, MD

S/P adequate intrapartum prophylaxis.

Routine or ritual circumcision

ICD-10-CM: Z41.2 ICD-9-CM: V50.2 ICD-10-CM: Z38.00 ICD-9-CM: V30.00

Unknown - Present

RESOLVED: Single liveborn infant delivered vaginally

2/14/2020 - 5/18/2020

Overview Addendum 2/14/2020 2:06 PM by Myriam Ortiz-de Jesus, MD AGA male infant , Ballard at 37 weeks. Will need car seat test.

Patient as-of Visit

Allergies as of 12/16/2021

Allergies last reviewed by James A. Wayne Jr., MD on 12/16/2021 1021 No Known Allergies

Immunizations as of 12/16/2021 Immunization

Administered On

DTaP / HiB / IPV

04/27/2020, 07/09/2020, 09/03/2020 02/14/2020, 04/27/2020, 09/03/2020 04/27/2020, 07/09/2020, 09/03/2020 04/27/2020, 07/09/2020, 09/03/2020

Hepatitis B, Pediatric/Adolescent Pneumococcal Conjugate - 13 Valent

Rotavirus Pentavalent

Generated on 7/19/22 2:38 PM

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