Assignment: Case Studies: Chapter 22 Medicine
1.
This is an 80-year-old male who has been suffering for the past eight weeks with a nonhealing ulcer on the lateral aspect of the right calf. The ulcer does look better today, having gone from 6 cm to 4.3 cm. It is still oozing, and there is some necrosis around the lower edge of the wound. I debrided the wound with a scalpel into the dermal layer of all devitalized tissue. Bacitracin was applied, and the wound was dressed. The patient was instructed to care for the wound until he presented again in two
weeks.
CPT code(s): 97597
2.
This is a 32-year-old, Type 2 diabetic female. She was diagnosed approximately two weeks ago and now presents for an initial assessment and intervention for medical nutrition therapy. She does not want to have to take insulin, so her doctor agreed that, with some nutrition counseling and exercise, she may be able to avoid it. We spent 30 minutes discussing the American Diabetic Association diet plan and how to implement it. We also discussed exercise and how to work it into her schedule. She will follow up with me in two weeks to see how things are progressing. If she has any problems before then, she will call this office.
CPT code(s): 97802- 97802
3.
Marcus is a 2-year-old child who presents here with his mother. He is running a fever of 101 and is very lethargic for a 2-year-old. He is not eating or drinking, and his mom said he has vomited each time he tries. She did get a few drops of water into him prior to this visit, but nothing else. He has not had a wet diaper in the past six hours. An IV of
D5-1/2 normal saline + 30 mEq KCl was started. We performed the IV therapy for one hour, after which Marcus was acting much improved. His temp was down to 98. We gave him a popsicle, which he kept down. Mom was instructed to let us know if he does
not have a wet diaper over the next few hours or if his condition worsens.
CPT code(s): 96360
