After the patient describes the pain and its duration, the medical assistant decides if the pain is chronic or acute and records that in the medical record.
Answer the following statement true (T) or false (F)
False
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The physician documents a moderate number of diagnoses and/or management options, a straightforward amount and/or complexity of data to be reviewed, and a moderate risk of complications, comorbidities and/or mortality. What is the overall level of medical decision making?
A. Straightforward B. Low C. Moderate D. High
Bilateral compression of Eustachian tubes:
A) H68.131, H68.132. B) H68.133. C) H68.139. D) H68.123.
The condition established after study, that is the chief reason for the hospital admission is called the _____.
A. primary diagnosis B. first listed diagnosis C. principal diagnosis D. admitting diagnosis
A 24-year-old male arrived at the emergency department (ED) via ambulance. 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 by a hornet. He immediately experienced generalized pruritus, urticaria, angioedema, and nausea. His golf partner, who was knowledgeable about reactions from stinging insects, pulled out his cell phone and called 911. The ambulance crew arrived within a few minutes, administered epinephrine, and transported him to the ED. In the ED, the emergency physician performed a level 3 E/M service and explained to the patient that his diagnosis of anaphylaxis was a reaction to a hornet sting. The physician then ordered another intramuscular injection of
epinephrine (0.1 mg). Once the patient's symptoms resolved, he was discharged with an oral antihistamine to be taken for 24 hours and a kit containing a prefilled syringe of epinephrine and an epinephrine nebulizer for prompt self-treatment for any future reaction. He was advised to see a physician for evaluation of venom immunotherapy (desensitization).