Initial Post Use your lecture materials to determine what CP
Initial Post Use your lecture materials to determine what CPT E&M… Initial PostUse your lecture materials to determine what CPT E&M Code to utilize for this ‘new patient’ encounter.You may choose to assign the code based on the anticipated/guestimate amount of time the provider would spend with the patient in the encounter or you may choose to utilize the Medical Decision Making (MDM) approach. If you choose the MDM include the following information in your discussion:the level of history taking achieved – identify the history elements presentthe type of exam performed – identify the number of systems and bulleted points in the notethe level of medical complexity encompassed – include # of points for a) diagnoses/management options, b) amount/complexity of data reviewed, and c) level of risk for complications, morbidity, mortality Chief Complaint: “I don’t know how much longer I can go on like this. I’ve been down in the dumps for years and it isn’t getting any better.” History of Present Illness:75-year-old white male present to clinic with above complaint. Lost his first, the “love of his life” wife 19 years ago. Remarried 2 years after her death and states he probably married again too soon reporting his current wife is difficult. He describes an instance, when he was at work, the second wife would not let his son, daughter-in-law and new grandbaby into his house to visit until he got home from work. The second wife also insisted that he no longer visit with his deceased wife’s family telling him ‘when you married me, you divorced that whole family’. Conversations with his wife about his concerns resulted in only short-term changes in her approaches and behaviors. Now his wife insists they sell the house he has lived in for 46 years. He reports that his memory and ability to make simple decisions have been deteriorating significantly over the last several months. His wife suggested he probably has Alzheimer’s and should go see his primary care provider about his memory issues. He reports that he engages with modest exercise daily, eats well but is waking up numerous times at night and is usually “up for good” by 5am. He blames his disrupted sleep pattern on his feeling of fatigue starting around 9am. He reports all these circumstances as contributing to his increased depression and his desire to “give up the fight”. PMH:reports usual childhood illnesses inclusive of measles, mumps and chickenpoxtraumatic injury, likely secondary to ‘blast’ effect, sustained during the bombing of Pearl Harbor where he was stationed as a cook; he suffered a hearing loss for six months after the bombing and was diagnosed at 54 with a rare eyes disorder resulting in poor peripheral vision that is thought to be secondary to this traumaFamily Hx:Father died at 67 secondary to colon cancer; mother died at 24 secondary to influenza during an epidemic (he was 2 years old at that time)No know family history of depression or other mental illnessSocial Hx:HS graduate, married to HS sweetheart for 27 years then widowedCurrent marriage of 17 yearsRetired after 25-year banking careerAttends Catholic mass regularlyDrinks 1-2 beers several times a week, denies episode of intoxication; never smoked or used illicit drugsDrinks hot tea, reporting coffee causes too much GI distressNever driven a motor vehicle secondary to poor peripheral visionROS:Denies HA, body aches, dizziness, fainting spells, tinnitus, ear pain, ear discharge, nasal congestion, diarrhea, constipation, change in appetite skin abnormalities, or genitourinary symptomsDenies periods of extreme irritability or elation associated with periods of sadness; denies feeling more depressed during the winter months than other seasonsReports fatigued most of the time, often feels stiffness in his neck and shouldersDenies homicidal ideations, hallucinations, paranoia or delusionsReports suicidal thoughts, has a 22-caliber rifle at home and has considered using to end his lifeSIGECAPS:Reports – poor sleep maintenance, loss of pleasure, he feels as though he remarried too soon, he is experiencing fatigue, he is experiencing memory disturbances, eating well, no problems maintaining exercise regimen, is having suicidal ideations Medications:No routine medicationsAllergies:None Physical Examination:Constitutional – BP 118/73, P 83, RR 16, T 98.8, Ht 71 in, Wt 174 lbs, BMI 24Integument – skin, hair and nails unremarkableHEENT – PERRLA, EOMs intact, nares patent without discharge noted, TMs gray and shiny bilateral, numerous silver amalgams notedNeck – supple without adenopathy, no thyromegalyLungs – CTAHeart – RRR without murmur/gallopAbdomen – soft, non-distended, active bowel sounds, non-tender, no organomegalyGenitalia/Rectum – deferredMusculoskeletal – no gross abnormalities or major limitations of ROM noted Neurologic – CNs II-XII intact, finger-to-nose test negative, DTRs 2+ and equal bilateral, sensory capacity intact upper and lower extremities intact bilateralMental status – PHQ 9 score is 19Diagnostics – Na 138 meq/L, K 4.2 meq/L, Cl 102 meq/L, HCO3 27 meq/L, Bun 11 mg/dL, Cr 0.9 mg/dL, fasting Glu 106 mg/dL, Ca 9.5 mg/dL, Mg 1.8 mg/dL, AST 34 IU/L, ALT 42 IU/L, GGT 38 IU/L, Alb 4.4 g/dL, TSH 2.8, Vit B12 98 pg/mL, Folic acid 333 ng/mL, PSA 4.9 ng/mL, Hgb 14.3 g/dL, HCT 41.4 %Urine dipstick – 5.8 pH, SG 1.016, all other parameters negative Assessment:F32.1 Major depressive disorder, single episode, moderateR45.851 Suicidal ideations/thoughtsR73.03 PrediabetesE53.9 Vitamin B deficiencyPlan:Major depressive disorderDiagnostic – noneTherapeutic – citalopram 20mg take 1 by mouth daily dispense #30 with 2 refills Educational – effects of citalopram may not be fully evident for up to 3 or 4 weeks; if you note fatigue exacerbated from the citalopram take it at bedtime; RTC in 1 month for follow up Consultation/Collaboration – none Suicidal ideations/thoughtsDiagnostic – noneTherapeutic – same as diagnosis #1Educational – same as diagnosis #1; educate on the potential negative impact of his current intake of beer – educate on how to safely reduce this consumption and to avoid abrupt cessation; educate on need to remove the 22-caliber rifle from his home; provide information on suicide hot linesConsultation/Collaboration – referral for counseling PrediabetesDiagnostic – noneTherapeutic – noneEducational – nutrition education aimed at making dietary lifestyle choices of low glycemic index foods (<55 GI) that aid in development and maintenance of stable insulin and glucose levelsConsultation/Collaboration - noneVitamin B deficiencyDiagnostic - noneTherapeutic - hydroxocobalamin 1000 mcg IM during this OV; start on 2mg oral B-12 daily; recheck Vitamin B-12 level in 2 to 3 monthsEducational - nutrition education on foods high in B-12Consultation/Collaboration - none Health Science Science Nursing NU 671
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