Get Answer: Reason Consultation Choking Question Guide
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Original Question
Reason for Consultation: Choking Requested by: Hospitalist service History of Present Illness: Mr. Armstrong is 53 y/o Caucasian male patient with past medical history significant for heroin and alcohol dependence who was drinking his vodka at work and eating then he choked and passed out. A friend of his did Heimlich maneuver and patient eventually expelled a piece of steak. When EMS arrived, the patient was hypoxic at the scene. This was after fire department EMS had arrived and given the patient 2 mg of intranasal Narcan which had minimal effect. The patient then, significantly hypoxic and non-responsive, was bagged for 10 minutes. After the patient was bagged for 10 minutes the patient became awake and somewhat alert. Chest x-ray at ED showed vascular congestion suggest aspiration pneumonia. The patient was started on IV clindamycin. Pulmonary service was consulted for suspected aspiration pneumonia management. Medical History: R lung pneumonia, R side empyema, opioid dependence, alcohol dependence Family History: CAD Socially History: Lives alone, smoker since he was a teenager and smokes curently 1 ppd, drinker in the last 10 yrs, drinks vodka, 1 pint daily, heroin on daily basis for the last 10 yrs. Worked in a warehouse for 30 years. Admits to drinking, smoking, and using heroin on the job. Interested in going to rehab. Medications: Docusate 100mg, Folic acid 1 tab, Metoprolol 12.5mg, Multivitamin Review of Systems Constitutional: No fever, No chills. Eye: No recent visual problem, No visual disturbances. Ear/Nose/Mouth/Throat: No decreased hearing, No ear pain. Respiratory: Cough, Sputum production, No shortness of breath. Cardiovascular: Peripheral edema, No chest pain, No palpitations. Gastrointestinal: No nausea, No vomiting, No diarrhea, No constipation, No abdominal pain. Hematology/Lymphatics: No bruising tendency, No bleeding tendency. Musculoskeletal: No joint pain, No muscle pain. Neurologic: No numbness, No tingling. Psychiatric: No anxiety, No depression. Vitals: Temperature: 98.6°F Pulse: 72 Respirations: 20 Blood Pressure: 160/90 SpO2: 98% on room air Physical Examination: General: Alert and oriented, Well nourished, Well developed, No acute distress. Eye: Pupils are equal, round and reactive to light, Intact accommodation. HENT: Normocephalic, Atraumatic, Oral mucosa is moist. Respiratory: Lungs CTA bilaterally, No wheeze, Respirations are non-labored, Breath sounds are equal. Cardiovascular: Regular rate, Regular rhythm, S1 auscultated, S2 auscultated, systolic murmur. Gastrointestinal: Soft, Non-tender, Non-distended, Normal bowel sounds. Musculoskeletal: Normal range of motion, Normal strength. Integumentary: Dry, Intact. Neurologic: Alert, Oriented, No focal defects. Psychiatric: Cooperative, Appropriate mood & affect. Impression/Plan Aspiration pneumonia-Pt was started on Clindamycin 900mg IVPB Q8, got total of 2 doses Opioid and alcohol dependence- hospitalist staff will monitor for withdrawal Tobacco dependence-smoking cessation counseling performed. Discussed going to rehab for drug and alcohol dependence in depth with patient. Total time taking care of this patient and stabilizing aspiration condition including significant counseling and coordination of care was one hour. what are the correct cpt codes.
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