Using the coding techniques you have learned, carefully read… Using

Using the coding techniques you have learned, carefully read… Using the coding techniques you have learned, carefully read through the case study and determine the most accurate diagnosis code(s). Remember, check the chapter-specific, subchapter-specific, and category-specific notations within the Tabular List. Then, determine the most accurate procedure code(s) along with any modifier(s), if appropriate.  ADULT HEALTH ASSOCIATES720 LONG STREET • ETERNITY, FL 32711 • 407-555-7322PATIENT: ALDERS, STEFANACCOUNT/EHR #: ALDEST001DATE: 04/22/18Attending Physician: Amanda Christoper, MDThis new patient is a 76-year-old male, referred to me by Dr. Theodore Lee, the family physician. He resides in his own two-story house, where he enjoys listening to the radio and the occasional record and tending to his garden. He denies ever marrying and states that he does not have any children. He attended 1 year of community college, after which he obtained employment as a clerk in a lawyer’s office. He kept this job for 40 years and retired when he was 67. He had an older brother, who was killed during World War II, and he has an older sister (80 years old), who resides in a nearby nursing home and whom he visits occasionally. His native language is French; however, he speaks and understands English very well. He still drives his own car for occasional trips but has expressed concern lately about getting lost when driving outside of his neighborhood.The patient attends an adult day program affiliated with a senior center twice a week. He has had several falls over the last 6 months and fractured a rib during the last fall incident, 4 months ago. Currently, he receives nursing service from home care once a week to monitor medications. He used to visit his sister once a week in a nearby nursing home, but the frequency of the visits has lessened over the past few months.   Over the past month or so, day program staff noticed the patient’s personal appearance is deteriorating. There are days when he wears soiled clothes, and his hair is not always clean or even combed. Patient showed up at the center on the wrong day for preplanned activities three times in the past 2 months. It appears that he is forgetting the names of staff and other members of the group whose names he knew. He appears more withdrawn and seems to have trouble following conversations. Maxine Shaw, MSW, the social worker at the adult day program, recommended this geriatric assessment  to Dr. Lee, who referred the patient to me.ASSESSMENT: The patient has a history of being a highly anxious person; he has a history of benzodiazepine use, as well as a history of psychiatric admissions for depression and anxiety. He states he has been experiencing increased anxiety following a diagnosis of skin cancer 7 months ago. He has asthma and uses Ventolin for control of symptoms. He states that he frequently calls his family physician, Dr. Theodore Lee, regarding the asthma attacks.VITAL SIGNS: Temp: afebrile; Resp: 17—accessory muscle use unremarkable; BP: 125/85 supine, 128/80 sitting, and 125/85 standing; weight: 145 lb., relatively stable (according to patient records from Dr. Lee); P normal; pulse oximeter O2 sat: 80%ATTITUDE: Patient is compliant and appears to be slightly resentful of the idea that something is wrong with him. He is slightly slow in some responses.GAIT: Patient is mildly unstable. Movement is slow, unsteady, and purposeful. At times, it appears that he tries to move and his feet are not quite following. FOLSTEIN MINI-MENTAL STATUS EXAM (MMSE): Score of 19, indicating possible depression and some cognitive impairmentINTEGUMENTARY SYSTEM: Skin is slightly pale; some diminished elasticity; slightly dehydrated. No signs of skin cancer, decubitus ulcers, or other ulcerations or wounds. There is some bruising, mostly on extremities, all of which appear to be normal for a patient of this age. No lesions are evident. HEAD: No signs of head trauma; no signs of Paget’s disease.EYES: Screening funduscopic examination is negative for cataracts. Visual fields for glaucoma—mild bilateral cataract developing in left eye; Snellen eye chart for rapid test of visual acuity is normal.EARS: Bilateral hearing aids for SNHL in the left ear and a mixed hearing loss in the right ear as a result of a stapedectomy when he was a child, which caused a conductive hearing loss. Some cerumen impaction, which is normal for patients who wear hearing aids.NOSE: No nasal obstructionOROPHARYNX: Patient wears upper and lower dentures that appear to fit correctly. No evidence of leukoplakia, cancers, erosions. Throat examination results show no throat infections or airway obstruction.NECK: ROM is unremarkable. Lymph nodes show no signs of malignancy. Cervical lymph nodes show no signs of infection, trachea is not deviated from midline, thyroid gland—no nodules indicating malignancy, thyromegaly is negative for hyperthyroidism. Carotid arteries—possible carotid occlusion. Thromboembolic risk is moderate, and auscultation for bruits is negative.LYMPH NODES: Posterior auricular, preauricular, supramandibular, anterior and posterior cervical, supraclavicular, axillary, and inguinal lymph nodes are all unremarkable.SPINAL/BACK: Evidence of moderate kyphosis. There is no spinal tenderness or any associated kyphos. There is some flank tenderness near the area of the previous rib fracture. Back mobility is limited.CHEST/LUNG: No signs of pulmonary edema, obstructive lung disease, pneumonia, or TB.HEART: PMI and character of apex beat—unremarkable; parasternal lifts and thrills—unremarkable; no added heart sounds (S3/S4) or murmurs; carotid beat during auscultation (for upstroke for AS)—unremarkablePERIPHERAL VASCULAR: Pulses checked: Bilateral temporal—OK, carotid—slow, brachial—OK, radial—OK, femoral—OK, popliteal—OK, dorsalis pedis—OK, posterior tibialis—OKABDOMINAL: UnremarkableMUSCULOSKELETAL/EXTREMITY: Cyanosis, clubbing, edema, capillary refill appear unremarkable; no deformities; patient’s shoes seem to be too large, thereby affecting gait; muscle strength and ROM are limited and not outside of age-appropriateness.NEUROLOGIC: Gait/fall risk: “get up and go” test (coordination and strength), Tandem Romberg, retropulsion, 360 degree turn—slow, affected. Coordination is within age range; however, strength is a concern. Wasting (local and generalized) and stigmata of stroke and common motor diseases is somewhat apparent. Cerebellar exam: finger to nose, rapid alternating movements, heel-knee to shin, Romberg—all slow but functional.GENITOURINARY EXAM: Digital rectal examination—unremarkable; patient denies fecal impaction or urinary frequencyDX: Arteriosclerosis of coronary artery, rule out normal pressure hydrocephalousPLAN: Screening for arthritides; hemoccult test; MRI head; carotid artery angiography—bilateralAmanda Christoper, MDAC/mg D: 04/22/18 09:50:16 T: 04/25/18 12:55:01  Be sure to list the codes, one code per box, in the correct sequence, from top to bottom, and in the proper row. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices. Please list modifiers with the code they relate to as necessary. Include a hyphen in between the code and the modifier. Example Procedure: 43846-74 or for Anesthesia: 00797-P2. You may not need all of the spaces provided.      Health Science Science Nursing HITT 2335 Share EmailCopy link Comments (0)

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