MO 232 Week 6 Practice

Week 6 Practice E/M In the following scenarios provide answers to questions; then Evaluation and Management CPT’s and ICD-10’s. There are no Procedures or HCPC’s this time. Each scenario is 15 points 1. A patient with rectal bleeding was seen in the office of a gastroenterologist. The patient’s primary care physician requested that the gastroenterologist provide advice about this case. The specialist conducted a comprehensive history and exam, and medical decision making was high. The consultant documented his findings and communicated them via written report to the primary care physician Code(s ) _ 99245 _______________________________________________________ 2. Dr. Michaels provides E/M services for a patient in acute hysteria who has been admitted to the emergency department . After performing a problem-focused history and examination with straightforward medical decision making, he determines that the patient is suffering from acute grief reaction secondary to the death of her granddaughter due to sudden infant death syndrome. At discharge, the patient is in complete control of her actions and is referred to a SIDS organization Code(s) __ 99281 _________________________________________________________ 3. Bryson admitted urgently yesterday afternoon for additional EEG monitoring to document ictal onset patterns.  Seizures at home had increased in frequency over the past 24 hours, with clustering episodes of left upper extremity numbness consistent with clinical seizures. Today his EEG has shown persistence of intermittent right central parietal slowing, but no evolved seizures as of yet.   Active Hospital Problems   Diagnosis Date Noted • Headache • Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus (HCC)   Impression: Intractable focal epilepsy.  Video EEG monitoring as part of phase 1 epilepsy surgery evaluation.   Plan: Continue video EEG monitoring to document ictal onset patterns Continue to hold lacosamide and valproate. Midazolam rescue.     I personally spent a total of 20 minutes in consultation with this patient and family today for this subsequent inpatient visit, of which >50% was spent in counseling and coordination of care. Codes _ R51 , G40.119 , 99252 ___________________________________

4. Subsequent Hospital Inpatient Visit or Critical Care (EXTRA CREDIT IN RED NEXT TO ABBREVIATION.) Interval History : Patient had two episodes of SVT (supraventricular tachycardia) one ending in 150j shocked with return to sinus rhythm. Since then only minor rises in arrhythmia. Feels anxious from the events of yesterday. Pt (patient) is sleeping this morning. Physical Exam : Last Vitals: BP (Blood pressure) 97/75  | Pulse 94  | Temp 36.7 °C (98.1 °F) (Axillary) | Resp (respiratory rate) 22  | Ht 1.651 m (5' 5")  | Wt 68.4 kg (150 lb 12.7 oz)  | SpO2 (oxygen saturation in blood) 98%  | BMI (body mass index) 25.09 kg/m²  | BSA (body surface area ) 1.77 m² 24 Hour Vital Min/Max:  Systolic (24hrs), Avg:97 , Min:82 , Max:115  Diastolic (24hrs), Avg:72, Min:61, Max:87 Pulse  Min: 86  Max: 159 Temp  Min: 36.7 °C (98.1 °F)  Max: 36.8 °C (98.2 °F) Resp  Min: 9  Max: 28 SpO2  Min: 97 %  Max: 100 %   General: AOx3 (alert and oriented). Sitting up in bed CV (cardiovascular): regular rate and rhythm, no murmur, rubs or gallops, S1/S2 nl. Pulm: Good air entry throughout bilaterally. No wheezes or crackles GI (gastrointestinal) : Normoactive bowel sounds. Soft, no distention or tenderness Extremities: Warm. 2+ bilateral radial and PT pulses. no LE edema.    LABS CBC, Liver tests and chemistry panels all normal except: Low NA; Low Hemoglobin and hematocrit Assessment and Recommendations: Mr. Patient is a 40y.o. male w/ PMHx (past medical history) of chronic systolic heart failure 2/2 methamphetamine abuse (last use approximately June 2020), and history of LVT (left ventricular thrombus) and RLE (right lower extremity) ALI (acute limb ischemia) s/p embolectomy 3/20/2020 admitted to CICU on 3/29/2021 for management of severe decompensated heart failure and severe cardiogenic shock.   #Acute on chronic combined systolic/diastolic HF (heart failure): 2/2 methamphetamine abuse. Has LBBB (left bundle branch block) but CRT-D ( cardiac resynchronization therapy defibrillator) was unable to be placed previously d/t complex anatomy. NYHA (new York heart association) class IV symptoms. ACC stage D (refractory heart failure requiring specialized interventions). He initially required dual inotropes but weaned to 0.5 mcg/kg and remains dependent on it. LVAD (left ventricular assist device) implantation and transplant are not feasible d/t psychosocial barriers. Currently working on a plan for home discharge with plans to follow up and development of a stable living situation   #SVT (supraventricular tachycardia) #AKI (acute kidney injury): Cr bumped up to 3.40 over the weekend likely in the setting of attempt to up-titrate vasodilator therapy but is now improving back down to baseline  #h/o LV (left ventricular) thrombus / current left subclavian thrombus vein #Iron deficiency anemia

GU: #13 dilator passed easily to hub. Flatus with stimulation. Moist, erythematous perianal rash with several satellite lesions   Musculoskeletal: normal muscle bulk and tone for age and stage of development Neurologic: normal affect for age and stage of development, no apparent neurologic deficit   Assessment: Little Boy is a 5 m.o. M   with history of Hirschsprung's Disease s/p pull-through in Jan of this year, stooling regularly with BID dilations, going well. Given recent bout of constipation, will plan to start weaning dilations next week. OK to do extra dilation or irrigation PRN for constipation or distension. Continue Nystatin to diaper rash.   (Continued on next page)                         Plan: - Dilation taper: Current schedule - #13 dilations BID                         Next week - Daily dilations with #13                         Week after - Every other day dilations x2weeks                         Then - 2x weekly dilations until your next follow-up - F/u in APP clinic in 3 months - Also sent Rx for Nystatin powder to dry out candidal rash - Family to call with questions or concerns.   Codes:_ Q43.1, L22, Z09, 99213, 99070 ____________