Samantha68516
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Is it true that the nature of the presenting problem should be the driving factor for E/M selection?
Example:
A patient presents with ear pain, runny nose, and fever.
HPI: 3 year old here today because he has been having ear pain and an ongoing fever for 4 days. Mom has been giving the patient Tylenol for fever. The patient has also had a runny nose.
ROS: Constitutional: Fever for 4 days.
ENT: Ear pain and runny nose.
Exam: General: Crying and holding right ear.
Eyes: Tears but not injected.
ENT: Right TM: Bulging, with purulent drainage.
Left TM: Inflamed, swollen, tender.
Nasal: Clear drainage present.
Respiratory: Clear to auscultation, no wheezing.
Skin: Clear, pink, no rashes.
Assessment: Acute, Suppurative Otitis Media
URI
Plan: Prescription of Amoxicillin for ASOM, and supportive care for URI. Return if symptoms persist or worsen.
Please provide input regarding the E/M level selection for the above example, and information on presenting problem being the driving factor of selecting and E/M level.
Thank you!
Samantha
Example:
A patient presents with ear pain, runny nose, and fever.
HPI: 3 year old here today because he has been having ear pain and an ongoing fever for 4 days. Mom has been giving the patient Tylenol for fever. The patient has also had a runny nose.
ROS: Constitutional: Fever for 4 days.
ENT: Ear pain and runny nose.
Exam: General: Crying and holding right ear.
Eyes: Tears but not injected.
ENT: Right TM: Bulging, with purulent drainage.
Left TM: Inflamed, swollen, tender.
Nasal: Clear drainage present.
Respiratory: Clear to auscultation, no wheezing.
Skin: Clear, pink, no rashes.
Assessment: Acute, Suppurative Otitis Media
URI
Plan: Prescription of Amoxicillin for ASOM, and supportive care for URI. Return if symptoms persist or worsen.
Please provide input regarding the E/M level selection for the above example, and information on presenting problem being the driving factor of selecting and E/M level.
Thank you!
Samantha