Wiki Intnsivist (MDM) Subsequent visit

[daniel]

I'm saying yes, but going of this.


Is this a HIGH MDM.

I'm just trying to get a feel for interpreting this, I came from a Family Practice setting doing E/M, and thats a different mind frame from interpreting Family Practice MDM vs Intensivist MDM.


Impressions/plan:
#Acute on chronic respiratory insufficiency: trach removed 2/09 per mother. Likely from recurrent aspiration and mucus plugging, s/p diagnositic thoracenthesis without evidence of empyema on R. Acute episode 11/10 related to mucus plugging.
-cont chest PT, pulm toilet, bronchodilators, will change to BID and every two hours prn
-abx per ID, on merrem/flagyl
-cont NPO and aspiration precautions.

#PNA with parapneumonic effusion: s/p right sided thoracenthesis. Exudative but no evidence of empyema
-Continue Abx, O2 for now
-follow L effusion, consider thoracentesis if fever or leukocytosis. will monitor for now as pt clinically improving

#S/P hemorrhagic CVA with significant deficit. The patient is nonverbal.
-Continue supportive care, frequent turning

# G tube infection/ malfunction s/p replacement.
-tolerating tube feed, cont wound care

D/W Mom



thank you
Daniel

 

[daniel]

Any takers

 

[FTessaBartels]

See my response

See my response to your other question

F Tessa Bartels, CPC, CEMC