Blake Photo Time-Line

ONLC PEDIATRICS OCHSNER, BATON ROUGE REGION LA

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

Acct #: 72013284589 Enc. Date 5/19/2021

05/19/2021 - Office Visit in O'Neal - Pediatrics

Reason for Visit Cough Wheezing

Diagnoses

Codes

Comments

Wheezing - Primary

ICD-10-CM: R06.2 ICD-9-CM: 786.07 ICD-10-CM: J06.9 ICD-9-CM: 465.9 ICD-10-CM: H65.92 ICD-9-CM: 381.4

Acute URI

Left otitis media with effusion

Problem List as of 5/19/2021

Date Reviewed: 5/19/2021

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: P00.2 ICD-9-CM: V29.0

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 5/19/2021

Allergies last reviewed by Lois H. Gesn, MD on 5/19/2021 1028 No Known Allergies

Immunizations as of 5/19/2021 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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