![]() ![]() The ambulance crew arrived within a few minutes, administered epinephrine and transported him to the ED. ![]() His golf partner, who was knowledgeable about reactions from stinging insects, pulled out his cell phone and called 911. He immediately experienced generalized pruritus, urticaria, angioedema, and nausea. He had been playing a round of golf at the local golf course when just after teeing off on the third hole, he slapped his shoulder exclaiming that he had just been stung. (The office nurse contacted the local hospital to arrange for inpatient admission.) Instructions: Assign ICD and CPT codes for this case.ĭiagnoses: Anaphylaxis A 24-year-old male arrived at the emergency department (ED) via ambulance. The physician explained the findings to the patient, and agreed that immediate hospitalization for treatment and observation was indicated. Physical examination also revealed generalized abdominal tenderness. ![]() In the office today, the physician completed a Level 3 E/M service and ordered a four-view spinal X-ray, which revealed hairline fractures of the third and fourth lumbar vertebrae. Last night, he was examined and discharged from the local emergency room directly following the accident with no return-to-work instructions or limitations. He explained that the accident occurred when he raced his car through a railroad crossing on the way to work and was hit by a train, which pushed the automobile and its occupant 200 yards up the track. The patient complained of back pain following an automobile accident. Instructions: Assign ICD and CPT/HCPCS codes for this case.ĭiagnoses: Hairline fractures of the third and fourth lumbar vertebrae A 26-year-old established male patient arrived for his appointment, which was scheduled by the occupational health nurse from a local industry with the company physician. The patient was treated with the intravitreal injection of Lucentis, 0.1 mg, and follow-up evaluation scheduled in 2 weeks. He discussed the newly FDA-approved intravitreal injection of Lucentis for this condition. Upon completion of the Level 2 E/M service, the physician informed the patient of the diagnosis of atrophic macular degeneration with subfoveal occult choroidal neovascularization, left eye, and atrophic macular degeneration of the right eye. The studies revealed loss of visual acuity of the left eye blood pressure was within normal limits persistent central pigment epithelial detachment, trace fluid and hemorrhage along the nasal foveal margin and prominent perifoveal indistinct drusen of the left eye. Visual acuity, blood pressure, slit lamp exam, tension, biomicroscopy, optical coherence tomography and fluorescein angiogram studies were performed. The patient had noticed gradually worsening Amsler grid changes and central vision distortion since January. The ophthalmologist is a specialist in retinal-vitreous surgery, and he discussed with the patient treatment options for visual changes in her left eye. A 72-year-old female, who was referred by her optometrist to an ophthalmologist, arrived for her 11 a.m. Atrophic macular degeneration, right eye. Diagnoses: Atrophic macular degeneration with subfoveal occult choroidal neovascularization, left eye. ![]()
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