Additional laboratory and diagnostic tests: May be necessary to establish or evaluate a condition. Some tests, such as MRI, may require prior authorization from the patient’s insurance carrier. 

Consults: referrals to specialists, therapists (physical, occupational), counselors, or other professionals. If you are sending to hospital, what orders would you write for a direct admit? 

Therapeutic modalities: pharmacological and nonpharmacological management. 

Health Promotion: Address risk factors as appropriate. Consider age-appropriate preventive health screening. 

Patient education: Explanations and advice given to patient and family members. 

Disposition/follow-up instructions: when the patient is to return sooner, and when to go to another facility such as the emergency department, urgent care center, specialist or therapist. 

References (minimum of 3, timely, that prove this plan follows current standard of care).” 

L m  is a 13 years old male child came to the clinic with his father ,with a complaint of testicular pain on the left side of the groin region. The patient stated  that the pain started suddenly about two hours ago when he was playing the basketball match.The pain is sharp ,persistent and increase when he walks or moves. He rated the pain 9 on the pain scale from 0 to 10 .He is also experiencing nausea and vomiting once. Patient has not taken any medication for the pain.

Caleb tachycardic 120bpm

Left testicles swollen and erythema

Diaphoresis

Pain to left testicles

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Primary Diagnosis and ICD-10 code
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