Outpatient Case Patient Question & Answer Guide (With Explanation)
Students often encounter this when studying fundamental concepts.
What This Question Is About
This question relates to outpatient case patient and requires a structured academic response.
How to Approach This Question
Structure your response with introduction, analysis, and conclusion.
Key Explanation
This topic involves outpatient case patient. A strong answer should include explanation, application, and examples.
Original Question
Outpatient Case 7 – Patient Grace Hunter; E/M physician services while an inpatient (no diagnosis codes) Newborn Care of Grace Hunter Delivery Note: 11/20 of the current year, 2300. Called to provide pediatric standby during delivery for suspected nuchal cord. Mother G2, P1. Onset of labor 0730 with normal progression. Entered stage 2 labor at 2100. Fetal monitor showed occasional decelerations. Spontaneous rupture of membranes at 2110, fluid was clear. Noted to have nuchal cord at the time of the delivery. Otherwise uneventful course. O: Initial Apgar score 8/9. Weight 3,340g. Approximate gestational age 38 weeks. General: Pink with lusty cry. HEENT: Normal, moderate molding, minimal caput. Spine intact. Lungs: Clear bilaterally. Cardiovascular: No murmur noted, capillary refill less than 2 seconds. Assessment: Normal full-term newborn, noted to have nuchal cord with occasional decels, otherwise uneventful delivery. Plan: No further intervention at this time. Transferred to newborn nursery for routine newborn care and monitoring. Progress Note: 11/21/ of the current year, 0630 Subjective: Female newborn, gestational age 39 3/7 wks. Product of full-term pregnancy. NSVD. SROM epidural anesthesia, nuchal cord. Initial Apgar score 8/9. Mother is 32-year-old G2 P1. Pregnancy was significant for maternal hypothyroidism and vanishing twin syndrome. See delivery note for labor courses. EDU 24 Nov. initial prenatal care at 10 3/7 wks. Maternal labs: Blood type O positive, ABS neg, Rub immune, VDRL nonreactive, HIV neg, GBS neg, 1hr GTT 82, HBsAg neg. GC/Chem neg. Objective: Birth weight 7 lb. 6 oz., head circ 140, length 19 ¾, head: normocephalic. Fontanelles soft nonbulging. Mild caput, moderate molding. Skin: Pink and warm. Eyes: 1 red reflux x 2, PERRL. ENT: Nares patent, palate intact. TMs clear bilaterally. Lungs: Bilateral breath sounds equal, no accessory muscle use noted: Cardiovascular: Regular rate and rhythm, no murmur appreciated. Well-perfused, normal pulses. Capillary refill less than 2 second. Abdomen: Normal active bowel sounds, soft, no masses, three-vessel cord. No erythema or discharge at umbilical stump. Genitalia: Normal female, minimal engorgement, anus patent. Neuro: Lusty cry, good suck, reflexes: 1 rooting, 1 morrow, 1 grip, 1 Babinski reflex present bilaterally. Skeletal: Clavicle is intact. Spine: No dimples or defects noted. Hips: Normal range of motion, no click noted. Assessment: Healthy, full-term infant. No defects noted. Plan: Continue routine newborn care and monitoring. Hearing screen ordered. Check bilirubin, ABO, CBC, and Coombs given Rh1 mother. Continue breast feeding, no supplemental feeding at this time. Discharge Exam: 11/22 of current year, 1000 Subjective: 2 d/o female infant. Breast feeding q. 2 hr., 10 min each breast; mother denies difficulty with latching on (1 breast fed previous infant), 1 lusty cry when hungry, easily consoled. 1 wet diaper q 2-3 hours, 1 meconium diapers x 3 since birth. Objective: Weight 7 lbs. 1.5 oz., afebrile throughout admission Laboratory: Coombs negative, blood type B negative, bilirubin 12, HTC 37, hearing screen pass, initial PKU pending. Assessment: Normal, health term infant, s/p SVD Plan: D/C to home. Continue to breast feed. Follow-up in the clinic for weight check and repeat bilirubin in three days. Hep B and 2nd PKU in two weeks. Return to ED if temp is above 100.5 degrees F, no wet diapers over 12 hours, lethargy, or respiratory distress. E. Stang, M. D. The below E/M codes were assigned for 11/20 to 11/22. Are these codes correct? E/M codes assigned (no auditing of diagnoses is required for this case) 11/20 11/21 11/22 99460 99462 99462
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