Case Study: A 64-year-old female patient with Diabetes
1. Question : An established patient is seen in the hospital on day two of his hospital stay. The patient had been admitted through the emergency department with status asthmaticus and had been undergoing extensive respiratory therapy over the past 24 to 30 hours. The physician performs a detailed interval history and a detailed physical exam. The possibility of pneumonia complicating the asthma must be considered. The patient’s respiratory condition is still unstable. The MDM complexity was high.
Question 2. Question : A 13-year-old male was admitted yesterday for a tympanotomy. Post surgically, the child developed fever and seizures of unknown origin. A pediatric consultation was requested. This was done on the second hospital admission day and 24 hours after surgery. The history of present illness (HPI) was extended with a complete review of systems (ROS). A complete past/family/social history (PFSH) was elicited from the mother as part of a comprehensive history. A comprehensive examination was conducted on all body areas and organ systems. The MDM complexity was high.
Question 3. Question : A full-term healthy newborn girl received initial and subsequent hospital care services on July 7 and July 8, respectively.
Question 4. Question : A physician is called to the intensive care unit to provide care for a patient who received second and third degree burns over 50 percent of his body due to a chemical fire. The patient is in respiratory distress and is suffering from severe dehydration. The physician provides support for two hours. Later that day, the physician returns and provides an additional hour of critical care support to the patient.
Question 5. Question : A patient was in the delivery room ready to give birth. When the physician had the patient start pushing, possible complications for the infant were noted and the hospital pediatric neonatal specialist was notified of a possible need for her evaluation of this newborn. The pediatric specialist was notified at 9:20 am. At 10 am, she was informed via phone call from the OB/GYN that the infant had normal Apgar scores of 9 and 9.
Question 6. Question : A new patient diagnosed with mild intellectual disabilities and self-abuse is sent to a custodial care facility for admission. The patient’s family is no longer able to care for the patient at home. The care facility physician documents a problem focused history with a problem focused exam. The medical decision making documented was straightforward.
Question 7. Question : A 4-year-old female established patient received Evaluation and Management services, which included a problem focused history, an expanded problem focused exam, and medical decision making (MDM) of a low level. The patient is diagnosed with influenza.
Question 8. Question : A 75-year-old patient was just diagnosed with type 1 diabetes. This means that the patient will have to give himself insulin shots. The physician supervised the coordination of home health care, which required 30 minutes of his time.
Question 9. Question : A physician called an established patient to inform her that the results of a chest x-ray were negative. The call was 5 minutes in duration. The patient had previously been seen in the office 10 days ago.
Question 10. Question : Subsequent follow-up care is provided for a comatose patient transferred to a long-term care center from the hospital two days ago. The resident shows no signs of consciousness on examination but appears to have developed a minor upper respiratory tract infection with a fever and rales heard on auscultation. The physician performs an expanded problem focused history and a problem focused interval examination with respiratory status and status of related organ systems such as cardiovascular. The physician is concerned that the respiratory infection could progress to pneumonia and orders the appropriate treatment. The MDM complexity is moderate.Case Study: A 64-year-old female patient with Diabetes
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