New ER Outpatient Consultation
History
Chief Complaint: Mr. Marlboro-man is seen at the request of the Emergency Room doctor for evaluation of a left neck mass.
History of Present Illness: Mr. Marlboro-man states that the neck mass developed 4 months ago. It has slowly increased in size, but in non-tender. He had an URI a week before the mass appeared.
Review of Systems: The patient notes a 15 lb. weight loss and poor appetite. No dysphagia or odynophagia or hoarseness.
Past Medical History: As above, otherwise negative.
Past Surgical History: He underwent appendectomy at age 10.
Allergies: Sulfa drugs.
Medications: None.
Social History: He smokes 2 packs per day and has been doing so for 30 years. He occasionally drinks alcohol.
Family History: Thyroid goiter in his mother.
Circle the appropriate level:
CC: Documented Not-Documented
HPI: Brief Extended
ROS: Problem Pertinent Extended Complete
PMHx, PFHx, PSHx: Problem Focused Expanded Problem Focused Detailed Comprehensive
Level of History: Problem Focused Expanded Problem Focused Detailed Comprehensive
PMHx, PFHx, PSHx: Problem focused Expanded Problem Focused Detailed Comprehensive
Level of History: Problem focused Expanded Problem Focused Detailed Comprehensive
Physical Exam
Normal voice. Nasal exam without drainage, septum midline. Oral cavity and oropharynx with pink mucosa, no lesions or masses. There is 3cm firm, fixed and non-tender mass at level III in the left neck. No other cervical lymphadenopathy.
How many elements identified by a bullet? __________________________
What level exam is documented? ___________________________________
Medical Decision Making
Data: None.
Impression: Left neck mass in a smoker.
Plan: Obtain CT scan of the neck with contrast to further evaluate the neck mass. Return to clinic after scan for a fine needle aspiration of the neck mass.
cc: Dr. PCP
Circle the appropriate level:
Data: Minimal Limited Moderate Extensive
Diagnosis: Minimal Limited Moderate Extensive
Risk: Minimal Low Moderate High
Complexity of Medical Decision Making: __________________
Put It All Together
History ________________
Exam ________________
Medical Decision Making ________________
Code Documented ________________