How to Answer Procedure Codes History Questions (Complete Guide)

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Key Explanation

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Original Question

PROCEDURE CODES FOR: HISTORY OF PRESENT ILLNESS: This is a 12-year-old Caucasian female brought to the ER by her mother with a chief complaint of leg weakness. One week prior, she had a fever of 101.4F with vomiting and diarrhea. After 3days, the vomiting and diarrhea resolved. She was doing well until this morning when she fell while trying to get out of bed and could not stand or walk without support. She denies headache, blurred vision, tinnitus, vertigo, dysphagia, or incontinence. No history of toxic ingestion. Her immunizations are up to date. While in the ER, she complains that her arms feel weak. EXAM: VS T 37.0, P 84, R 24, BP 102/64. Height and weight are at the 25th percentile. She is alert, slightly fearful, but cooperative. HEENT: She has no nystagmus and no papilledema. Her extraocular movements are intact. Pupils are equal and reactive to light. No facial weakness or asymmetry is present. Heart, lung and abdomen exams are normal. NEURO: Strength 4/5 in the upper extremities, 3/5 in the lower extremities. DTRs 1221 in the upper extremities and absent in the lower extremities. Sensation is intact in all extremities. Cerebellar function is normal except for the weakness. No cranial nerve abnormalities are noted. She refuses to walk. CBC, electrolytes, BUN, creatinine, glucose, calcium and liver function tests are normal. Urine toxicology screen is negative. A lumbar puncture is performed. Opening pressure is normal. CSF analysis shows protein 146 mg/dL (high), glucose 70 mg/dL, 5 WBC per cu-mm, 1 RBC per cu-mm, and gram stain shows no WBCs and no organisms. An MRI of the brain and cervical spinal cord is normal. She is started on IVIG and over the next few days, she slowly regains strength in her arms and legs. However, she still requires assistance with walking at the time of discharge. DX: Guillain-Barre syndrome (GBS) She is referred to a rehabilitation hospital to continue outpatient physical therapy.

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