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Reason for Consultation: Sudden onset of weakness Requested by: ED Service History of Present Illness: This is a 55 y/o female patient has a history of dialysis and apparently presented to ABC Hospital on 08-15-XX with a sudden onset of weakness. Her history of includes ESRD secondary to membranoproliferative glomerulonephritis. She has also has a history of seizures and hypertension. She has had an AV graft placed. Past workup/records reviewed from outside hospital network including imaging studies show evidence of a CVA with a right hemiparesis. Initial head CT scan was negative on this ED encounter. MRI shows evidence of advanced atrophy with ischemic changes as well as two acute ischemic infarcts in the left thalamus on radiology interpretation this morning. Medical History: ESRD on HD, membranoproliferative glomerulonephritis, seizures, htn Past Surgical History: AV fistula Social History: Reportedly, she is married. She was ambulatory occasionally with use of an assisted device prior to this admission. Physical Examination: Clinical examination reveals an alert female, arousable, was presently being dialyzed. She has some decreased sensation on the right with a definite weakness noted in the right upper and right lower extremity, 4/5 strength in the upper extremities on the right and 4-to 3+/5 strength in the right lower extremity, 4+/5 strength is noted on the left. Reflexes are blunted. There is decreased response to pain on the right. No significant neglect was noted. Her hand dominant is unknown as well. Diagnoses: CVA with right hemiparesis. ESRD on HD Membranoproliferative glomerulonephritis Seizures, continue on Depakote Htn-continue on Lisinopril and Metoprolol Plan: At this point in time, PT, OT and speech therapy have been initiated. We will monitor her progress, consideration for inpatient rehab will be strongly given in this matter. what are the correct CPT codes Do not put diagnosis codes

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