Significant Symptoms: ï‚· Anxiety ï‚· Depression ï‚·

Significant Symptoms: ï‚· Anxiety ï‚· Depression ï‚· Ruminations ï‚· Social Anxiety ï‚· Physical symptoms; sweating, heart palpitations Vitals: ï‚· 127/80 ï‚· 98 ï‚· 18 ï‚· 60 ï‚· 90% ï‚· BMI 30 ï‚· 225 lbs. ï‚· 72″ Physical exam: ï‚· General: Well appearing, well nourished, in no distress. Oriented x 3, normal mood and affect. Ambulating without difficulty. ï‚· Skin: Good turgor, no rash, unusual bruising or prominent lesions. ï‚· Hair: Normal texture and distribution. ï‚· Nails: Normal color, no deformities. ï‚· HEENT: Head: Normocephalic, atraumatic, no visible or palpable masses, depressions, or scaring. Eyes: Visual acuity intact, conjunctiva clear, sclera non-icteric, EOM intact, PERRL, fundi have normal optic discs and vessels, no exudates or hemorrhages. ï‚· Ears: EACs clear, TMs translucent & mobile, ossicles nl appearance, hearing intact. ï‚· Nose: No external lesions, mucosa non-inflamed, septum and turbinates normal. ï‚· Mouth: Mucous membranes moist, no mucosal lesions. ï‚· Teeth/Gums: No obvious caries or periodontal disease. No gingival inflammation or significant resorption. Pharynx: Mucosa non- inflamed, no tonsillar hypertrophy or exudate. ï‚· Neck: Supple, without lesions, bruits, or adenopathy, thyroid non- enlarged and non-tender. ï‚· Heart: No cardiomegaly or thrills; regular rate and rhythm, no murmur or gallop. ï‚· Lungs: Clear to auscultation and percussion. ï‚· Abdomen: Bowel sounds normal, no tenderness, organomegaly, masses, or hernia. ï‚· Back: Spine normal without deformity or tenderness, no CVA tenderness. ï‚· Rectal: Normal sphincter tone, no hemorrhoids or masses palpable. ï‚· Extremities: No amputations or deformities, cyanosis, edema or varicosities, peripheral pulses intact. ï‚· Musculoskeletal: Normal gait and station. No misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions, decreased range of motion, instability, atrophy or abnormal strength or tone in the head, neck, spine, ribs, pelvis or extremities. ï‚· Neurologic: CN 2-12 normal. Sensation to pain, touch, and proprioception normal. DTRs are normal in upper and lower extremities. No pathologic reflexes. ï‚· Psychiatric: Oriented X3, intact recent and remote memory, judgment and insight, anxious mood and affect. ï‚· Breast: No nipple abnormality, dominant masses, tenderness to palpation, axillary or supraclavicular adenopathy. ï‚· G/U: Penis circumcised without lesions, urethral meatus normal location without discharge, testes and epididymides normal size without masses, scrotum without lesions. The level of medical complexity encompassed by including the number of points for the diagnoses/management options and the amount/complexity of data reviewed; then identify the level of risk for complications, morbidity, mortality In the discussion, explore how the ICD-10 Codes that you assigned impact third party payor reimbursement for this visit. Responses need to address all components of the , demonstrate critical thinking and analysis, and include peer-reviewed journal evidence to support the student’s position. SCIENCE

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