Chapter 8, Problem 1CPTM

Please review the following orders and answer the questions below.   Admit for outpatient observation Start IV per facility protocol MS04 2.0 mg IV q 4hrs PRN CBC, CMP, TS, Coag panel VS QD, call with out of range ASA 81 mg chewable QD Xanax .25 PO TID Ativan 2.0 mg/d IV LR 125 mL/hr Psych consult       What orders need clarification?

Please code the E/M code and any other procedures for the following case from your CPT coding book and add modifier if applicable: Location: Family medical center Encounter Date: 9/7/xx Provider: Snow Valley, MD Patient: Heather Williams Gender: F Age: 43-year-old established patient Chief Complaint: Rash, diabetes, HTN and shortness of breath after taking amoxicillin. Patient was placed in observation after an allergic reaction to the antibiotic. The amoxicillin was discontinued. Has severe dermatitis covering arms, stomach and legs. Patient was admitted to observation for further treatment and supervision. Later in the day the dermattis began fading and breathing became normal. Patient was discharged on the same date. Physician performed a detailed exam and a detailed history, and medical decision making was moderate. Diagnosis: Localized dermatitis and shortness of breath due to amoxicillin.

The nurse on the step-down unit is caring for a patient with a history of HTN. The telemetry monitor displays the following rhythm. The nurse questions why ___________ is not on the patient's orders, as this medication is important to prevent complications?  Protonix (Pantoprozole) Warfarin (Coumadin) Lasix (Furosemide) Nitroglycerin (Nitrostat)