Review the scenario provided and complete the assessment and plan for the patient Coding Assignment HPI:...
Review the scenario provided and complete the assessment and plan for the patient
Coding Assignment
HPI: The patient is a 63-year-old, white male who is a new patient to our office and set to establish with Dr. Smith December 2019. He came in today because he has been having some right leg swelling for several months, but has noticed it has been worsening over the past few weeks. He reports no recent long car rides. Denies any family or personal history of bleeding or clotting disorders. He took some OTC Diurex with no relief.
ROS: Denies any CP or SOB. Denies any fevers or chills. Denies any cough, congestion, or hemoptysis. He reports he has gained 5 lbs. in the past 2 years and has a good appetite. He denies any n/v/d, abdominal pain, urinary frequency or urgency.
Past Medical History: Umbilical Hernia repair 1995. Allergies: NKDA Social History: Married with 2 children. Current smoker 1 ppd, 30 yr. pack history. Drinks 12 beers per night. Retired driver for trucking company. Family History: Negative for diabetes. Negative for any bleeding/clotting disorders. He has a daughter with breast cancer.
Physical Exam: White male in no acute distress. 261 lbs. 5’8” BP 170/90. Pulse: 84. R: 20. Temp: 99.0 oral HEENT: PERRLA. TM’s: bilaterally are clear. Oropharynx: moist, no erythema or exudate noted. Neck: supple, full ROM, no JVD or bruits, no thyromegaly Lungs: CTA Heart: RRR w/o murmur, rub, or gallop Abdomen: positive bowel sounds, soft, non-tender, obese. No hepatosplenomegaly. Extremities: Pulses 2+ and symmetrical. Appears to have 2+ pitting edema in bilateral lower legs, minimally tender with palpation. Sensation intact.
Assessment:
- _____ Leg swelling
- ______ Elevated Blood pressure, without diagnosis of HTN
- ______ Tobacco abuse
Plan:
- Will check labs
- Order ECHO to evaluate EF and wall motion
- Start Lasix 40 mg PO every morning #30 with 0 refills
- Patient to follow up with me in 2 weeks
- Recheck BP at next visit – consider medication if remains elevated despite diuretics
- Total time spent with patient 30 minutes
- Keep follow up appointment with PCP 12/2019 to establish in clinic
- Smoking cessation education given
CPT: ___________
Homework Answers
Assessment
Bilateral leg pitting edema but came with right leg swelling
170/90mm/hg elevated bp
30 years of tobaco
Plan
CPT is current procedural terminology is a medical code set to
report medical surgical and diagnostic procedures of the individual entities with the insurance organisation.
Add Answer to:
Review the scenario provided and complete the assessment and
plan for the patient
Coding Assignment
HPI:...
Patient: B.A. Age: 57 Isolation: Contact- MRSA Allergies: Sulfa 0800 Assessment HPI B.A. is a 57...
Patient: B.A. Age: 57 Isolation: Contact- MRSA Allergies: Sulfa 0800 Assessment HPI B.A. is a 57 yo male with a history of uncontrolled Diabetes Type 2 diagnosed in 2008. Pt was admitted with c/o increased numbness and tingling, and decreased sensation in his lower extremities x 4days. Pt reports that he noticed a reddened swollen area on his right leg that appears to be spreading. Physical Examination BP: 134/86 Lt arm sitting HR: 96 regular rate and rhythm R: 18/min...
Now…look at the following case scenarios and determine which diagnosis is most likely to be applicable to the patient.&n...
Now…look at the following case scenarios and determine which diagnosis is most likely to be applicable to the patient. A 32-year-old female presents to the emergency room with complaints of abdominal pain. She describes generalized pain that started yesterday and worsened overnight. She indicates that the pain is now located in the RLQ. Upon auscultation, bowel sounds are hypoactive. Guarding noted with palpation, reports tenderness in RLQ, positive McBurney sign. Low grade fever noted, nausea with 2 episodes of vomiting...
patho of the disease, medication of choice,patho of the the medication, side effects, and patient education...
patho of the disease, medication of choice,patho of the the
medication, side effects, and patient education
B. Mr. Farrell is a 78-year-old white male patient who comes to your office complaining of increased left knee pain for the past 3to 4 months. He has had no history of recent injury. An X-ray done less than 4 months ago showed degenerative osteoarthritic changes. He has full range of motion and denies any recent swelling, pedal edema, or discoloration. He has been...
Dropbox Case Scenario: You are the triage nurse in the Emergency Department. Your patient, Mr. Sawyer,...
Dropbox Case Scenario: You are the triage nurse in the Emergency Department. Your patient, Mr. Sawyer, is a 50-year-old man who presents with severe abdominal pain, poor appetite, and fatigue. He states the pain awakened him from sleep and he began vomiting. He denies any relief from the pain and he can't get comfortable as the pain radiates to his back and right shoulder. He rates his current pain level as 10/10. He denies any previous medical or surgical history....
Case #1 History of Present Illness: The patient is 42 year old Caucasian male with no...
Case #1 History of Present Illness: The patient is 42 year old Caucasian male with no prior cardiac history. He presented to the emergency room at Green River Hospital complaining of chest pain. This morning he notices some numbness and pain in his left arm. Later in the day he developed pressure in the chest. This gradually worsened throughout the morning until shortly before lunch when he was rating the pain at 8/10 in severity and decided to go to...
Part One: For the following medical diagnoses, please describe the manifestations the patient will most likely...
Part One: For the following medical diagnoses, please describe the manifestations the patient will most likely present with. Please include pain characteristics (location, descriptions, onset, etc.) and associated signs and symptoms (such as nausea, abdominal signs, jaundice, etc.). Be as thorough as you can. Ask yourself this: if I get assigned a patient with this diagnosis, what things would I expect to see, what things would I assess for? Peritonitis Pancreatitis Cholecystitis Diverticulitis Part Two - Now…look at the following...
Question 3: Based on Mr. Sawyer's chief complaint describe your physical assessment. Be thorough & detailed...
Question 3: Based on Mr. Sawyer's chief complaint describe your physical assessment. Be thorough & detailed in your answer. (15 points) Question 4: Based on Mr. Sawyer's chief complaint what additional physical exam techniques / tests would you want to include in your physical assessment of him? Be thorough & detailed in your description. (20 points) Case Scenario: You are the triage nurse in the Emergency Department. Your patient, Mr. Sawyer, is a 50-year-old man who presents with severe abdominal...
Patient A.B. is a 70-year-old male who had a right total knee replacement done yesterday. His...
Patient A.B. is a 70-year-old male who had a right total knee replacement done yesterday. His past medical history includes osteoarthritis, hypertension, high cholesterol, diabetes mellitus, and GERD. During your initial shift assessment, the patient is noted to have swelling in his right calf and reports tenderness to touch in the calf region. You ask him to dorsi/plantar flex his right foot against resistance from your hand, and he indicates that the pain in his calf worsens with flexion. You...
Mr. Williams is a 69 year old male who arrived at the emergency department, complaining of...
Mr. Williams is a 69 year old male who arrived at the emergency department, complaining of severe vomiting & weakness for two days. Identifying Information: 69 yr old male History of Present illness: 69 yr old male presented to the ED c/o of severe vomiting & weakness for two days. He states he has taken the medications for vomiting but can't hold anything down. He feels dizzy when standing up and feels very weak. Currently being treated for tongue cancer....
10 questions For the Disease Summary for this case study, see the CD-ROM PATIENT CASE HPI...
10 questions
For the Disease Summary for this case study, see the CD-ROM PATIENT CASE HPI Mr. H.Y. is a 63-year-old male, who presents to the ER with a two-day history of high-grade fever with chills. "I don't feel well and I think that I may have the flu," he tells the ER nurse and physician. He also complains of "some painful bumps on my fingers and toes that came on last night." He denies IVDA. When asked about recent...
patho of the disease, medication of choice,patho of the the
medication, side effects, and patient education
B. Mr. Farrell is a 78-year-old white male patient who comes to your office complaining of increased left knee pain for the past 3to 4 months. He has had no history of recent injury. An X-ray done less than 4 months ago showed degenerative osteoarthritic changes. He has full range of motion and denies any recent swelling, pedal edema, or discoloration. He has been...
Dropbox Case Scenario: You are the triage nurse in the Emergency Department. Your patient, Mr. Sawyer, is a 50-year-old man who presents with severe abdominal pain, poor appetite, and fatigue. He states the pain awakened him from sleep and he began vomiting. He denies any relief from the pain and he can't get comfortable as the pain radiates to his back and right shoulder. He rates his current pain level as 10/10. He denies any previous medical or surgical history....
Question 3: Based on Mr. Sawyer's chief complaint describe your physical assessment. Be thorough & detailed in your answer. (15 points) Question 4: Based on Mr. Sawyer's chief complaint what additional physical exam techniques / tests would you want to include in your physical assessment of him? Be thorough & detailed in your description. (20 points) Case Scenario: You are the triage nurse in the Emergency Department. Your patient, Mr. Sawyer, is a 50-year-old man who presents with severe abdominal...
Mr. Williams is a 69 year old male who arrived at the emergency department, complaining of severe vomiting & weakness for two days. Identifying Information: 69 yr old male History of Present illness: 69 yr old male presented to the ED c/o of severe vomiting & weakness for two days. He states he has taken the medications for vomiting but can't hold anything down. He feels dizzy when standing up and feels very weak. Currently being treated for tongue cancer....
10 questions
For the Disease Summary for this case study, see the CD-ROM PATIENT CASE HPI Mr. H.Y. is a 63-year-old male, who presents to the ER with a two-day history of high-grade fever with chills. "I don't feel well and I think that I may have the flu," he tells the ER nurse and physician. He also complains of "some painful bumps on my fingers and toes that came on last night." He denies IVDA. When asked about recent...
Most questions answered within 3 hours.
-
39.4% of US homes continue to use a landline in addition to cell
phone service. 3...
asked 8 minutes ago -
Starting with benzene, synthesize 1-phenyl-1-butyne.
Show intermediates and reagents.
asked 1 hour ago -
Create a 32-run crossed array design with six control factors
and two noise factors such that...
asked 1 hour ago -
A 500g sample of sand from source A has the following amounts
retained on each sieve....
asked 1 hour ago -
In
your own words, please explain the essay by John Keynes wrote "The
End of Laissez...
asked 1 hour ago -
How are the matrix and pixels related? Why are smaller
pixels better for diagnostic quality?
asked 1 hour ago -
2. An AC generator has 80 rectangular loops on
its armature. Each loop is 11 cm...
asked 2 hours ago -
Please help me with this question. Consider Aldi’s current and
potential geographic markets (see Exhibit 4...
asked 2 hours ago -
What are the main components of the fermentation process and
give an explanation of each? Include...
asked 2 hours ago -
Explain which types of cells in the body (belonging to which
organs, etc.) are sensitive to...
asked 2 hours ago -
A single cable supports an 703-kg elevator car. What is the
tension in the cable when...
asked 2 hours ago -
among the three different ways to link CSS specifications to an
HTML document (inline CSS, document...
asked 2 hours ago