Question
Answered step-by-step
Asked by mnyangoro
A question from a book Role Development for the Nurse Practitioner chapter 15 case study two.
Robert Jones is 45 -year -old male who presents for diabetes. He has been struggling with blood sugar control. He travels for his job and eats out most days. He walks or goes to the gym when he can at least once a week. Takes metformin but forgets to take the second dose. AM BS 200-300, PM BS 300-400. Did not go to diabetic education classes “I could not fit then in to my busy schedule”.
Past medical history:
Back surgery for “protruding lumbar disc” 5 years ago
Depression
Allergies:Codeine; rash
Medications: Zoloft 100 mg QD, metformin BID
Family History: Osteoarthritis, DM, HTN; mother 75 y.o. Cerebral vascular accident; father deceased age 60 y.o.
Social History: Happily married to attorney for 15 years, works in sale, nonsmoker, no children < 3 alcoholic drinks weekly. Review of Systems: General:Denies fever, weight loss, actually gained 10 Ibs, night sweats Respiratory: Denies difficulties Cardiac: No CP or palpitations Gastrointestinal: Appetite good, denies problems GU: Denies urinary frequency, no nocturia Musculoskeletal: Denies numbness, weakness, or sensation of pain in the upper extremities. Physical Examination: General: NAD. HT 5'9", WT 285 Ib, BP 130/80, P-76, R-18 Cardiac RRR, S1,S2 no S3,S4, 3/6 SEM throughout precordium ( new finding), Lungs CTA,Abd: soft,+BS no HSM, extremities no edema noted What are the potential ICD- 10 codes in this case? How can the NP determine if this patient is a new patient versus an established patients at the clinic? What components of care will be used for reimbursement decisions for Mr.Jones? What type of physical examination best fits what was performed on Mr.Jones? If you were coding the visit for Mr. Jones, how would you determine what decision-making level you would choose? Provide your rationale, and be specific . SCIENCE HEALTH SCIENCE NURSING NRP 612
