daniel
True Blue
I'm saying yes, but going of this.
Is this a HIGH MDM.
I already pushed this through and upcoded it to a 99233.
I'm just trying to get a feel for interpreting this, I came from a Family Practice setting doing E/M, and thats a different mind frame from interpreting Family Practice MDM vs Intensivist MDM.
Impressions/plan:
# Altered Mental Status: likely related to meds. Now awake and responsive
# Pulmonary
1. acute resp failure s/p ETT 11/3-11/10
2. bilateral aspiration pneumonia
3. COPD
4. hypoxemia: combination of pneumonia, V/Q mismatch, atelectasis
5. OSA
-keep euvolemic
-cont oxygen support, wean as tolerate
-cont abx for tx of pneumonia: zosyn per Dr Ho for 4 more days
-pulm toilet, bronchodilators, IS, mobilization
-encourage CPAP with sleep for OSA
-wean steroid off 11/14
# Cardiac
1. Moderate AS
2. HTN
-keep euvolemic
-cont coreg, diovan and calcium channel blocker for BP control
# Endocrine
1. DM II: hyperglycemia exacerbate by steroid now off. Pt has hypoglycemia
2. Hypothyroidism
3. Hyperlipidemia
-followed by endocrine and stable on meds
# PICC line associated DVT
-coumadin x 3 months
# Leukocytosis, source not clear, r/o C diff colitis vs line sepsis
picc line DC 11/16, check tip culture
check C Diff, agree with oral vanco
#PPX-> scd and acid lowering,
Is this a HIGH MDM.
I already pushed this through and upcoded it to a 99233.
I'm just trying to get a feel for interpreting this, I came from a Family Practice setting doing E/M, and thats a different mind frame from interpreting Family Practice MDM vs Intensivist MDM.
Impressions/plan:
# Altered Mental Status: likely related to meds. Now awake and responsive
# Pulmonary
1. acute resp failure s/p ETT 11/3-11/10
2. bilateral aspiration pneumonia
3. COPD
4. hypoxemia: combination of pneumonia, V/Q mismatch, atelectasis
5. OSA
-keep euvolemic
-cont oxygen support, wean as tolerate
-cont abx for tx of pneumonia: zosyn per Dr Ho for 4 more days
-pulm toilet, bronchodilators, IS, mobilization
-encourage CPAP with sleep for OSA
-wean steroid off 11/14
# Cardiac
1. Moderate AS
2. HTN
-keep euvolemic
-cont coreg, diovan and calcium channel blocker for BP control
# Endocrine
1. DM II: hyperglycemia exacerbate by steroid now off. Pt has hypoglycemia
2. Hypothyroidism
3. Hyperlipidemia
-followed by endocrine and stable on meds
# PICC line associated DVT
-coumadin x 3 months
# Leukocytosis, source not clear, r/o C diff colitis vs line sepsis
picc line DC 11/16, check tip culture
check C Diff, agree with oral vanco
#PPX-> scd and acid lowering,