[Solved]: Discharge summary: Admitting diagnosis: Ataxia,…

Discharge summary: Admitting diagnosis: Ataxia, nystagmus, vomiting. R/O head injury. Discharge diagnosis: Grade 1 Ependymoma of the cerebellum, left flaccid hemiparesis, cerebellar ataxia duc to ncoplasm. Procedures: MRI, PET, Myelogram, Craniotomy History of present illness: Seven-year-old Hispanic male brought to ED by his mother with a two-day history of poor coordination, falls, and irritability. Today she noticed his cyes were “moving funny” and he began vomiting. Past medical history: Chronic otitis media, bilateral myringotomy and tubes at age 2. Allergies: Amoxicillin, Biaxin Hospital course: Unremarkable Discharge instructions: Dict as tolerated. Tylenol for pain. Post op check in Neurosurgical Clinic in one week. Appoint- ment with Pediatric Oncology Team in 3 days. Emergency department: Chief complaint: New onset clumsiness and repeated falls. Irritability and vomiting, unusual eye movements. HPI: Patient was in his usual state of good health until 2 days ago. Mother noticed he was tripping and falling and seemed to drag his left leg. He denied pain, just said his left side felt “heavy” and was not “working right.” This morning he refused breakfast and then began vomiting. Mother noticed his eyes were moving very quickly from side to side. She asked a neigh- bor to drive them to the hospital. Assessment/Plan: MRI to R/O head injury. Admit to Peds Floor. Admission history and physical: Chief complaint: Vomiting, left side weakness and poor coordination History of present illness: Patient describes feeling like his left side was “heavy” two days ago and that he fell down a lot when he was playing soccer. He does not recall striking his head when he fell. He denies pain. When he woke this morning, his stomach felt upset so he refused breakfast and watched some TV. He had trouble focusing on the TV because his eyes were “moving funny” and then he suddenly began vomiting. ICD-10-CM codes: (3 codes) ICD-10-PCS code: (1 code)