EBK CASE STUDIES IN HEALTH INFORMATION
EBK CASE STUDIES IN HEALTH INFORMATION
3rd Edition
ISBN: 9781337514538
Author: Mccuen
Publisher: VST
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(For items 96-101, kindly refer to the image below.) NAME: PANGANIBAN, REA B. DOB: NOVEMBER 25, 1975 SEX: F DIAGNOSIS: MYOCARDIAL INFARCTION DATE REQUESTED: 2/26/2021 TIME REQUESTED: 3:45 AM ROOM: ER AGE: 45 LABORATORY RECQUISITION CBC, BLOOD TYPING, ESR, PT-INR, APTT, TROPONIN I, BLOOD CULTURE (2 SITES), LDH, HEPATITIS PANEL REQUESTING NURSE: HUEGO, RN REQUESTING PHYSICIAN: CARIO, MD
Discuss, using the text, how you believe this case should be decided. Remember to reference specific ethical principles from the text: "A 13 year old girl, suffering from toxic shock syndrome, is sent directly from school to a local emergency room. Treatment is ordered, including fever-reducing medication and a strong course of intravenous antibiotics. The parents arrive just as the medication and equipment arrive in the emergency room. They announce they are Christian Scientists and wish to take their daughter home." The clinical approach to this case requires the application of the procedure by which medical indications, patient preferences, projected quality of life and contextual features be applied. How would you decide it given our readings so far?
Please code the E/M code and any other procedures for the following case from your CPT coding book and add modifier if applicable: Location: Family medical center Encounter Date: 9/7/xx Provider: Snow Valley, MD Patient: Heather Williams Gender: F Age: 43-year-old established patient Chief Complaint: Rash, diabetes, HTN and shortness of breath after taking amoxicillin. Patient was placed in observation after an allergic reaction to the antibiotic. The amoxicillin was discontinued. Has severe dermatitis covering arms, stomach and legs. Patient was admitted to observation for further treatment and supervision. Later in the day the dermattis began fading and breathing became normal. Patient was discharged on the same date. Physician performed a detailed exam and a detailed history, and medical decision making was moderate. Diagnosis: Localized dermatitis and shortness of breath due to amoxicillin.
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