see attached
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 chickenpox
traumatic 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 trauma
Family 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 illness
Social Hx:
HS graduate, married to HS sweetheart for 27 years then widowed
Current marriage of 17 years
Retired after 25-year banking career
Attends Catholic mass regularly
Drinks 1-2 beers several times a week, denies episode of intoxication; never smoked or used illicit drugs
Drinks hot tea, reporting coffee causes too much GI distress
Never driven a motor vehicle secondary to poor peripheral vision
ROS:
Denies HA, body aches, dizziness, fainting spells, tinnitus, ear pain, ear discharge, nasal congestion, diarrhea, constipation, change in appetite skin abnormalities, or genitourinary symptoms
Denies periods of extreme irritability or elation associated with periods of sadness; denies feeling more depressed during the winter months than other seasons
Reports fatigued most of the time, often feels stiffness in his neck
Use 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:
1. the level of history taking achieved – identify the history elements present
2. the type of exam performed – identify the number of systems and bulleted points in the note
3. the 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 chickenpox
traumatic 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 trauma
Family 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 illness
Social Hx:
HS graduate, married to HS sweetheart for 27
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