Using the current guidelines, select the best answer from the choices provided. Use the E/M Audit at
the end of this Assignment Pack to assist you.

Scenario 1

REASON FOR REFERRAL
The patient was sent to our office by her physician for a second opinion for her continuous pain in her right ankle and foot.

HISTORY OF PRESENT ILLNESS
This patient has severe arthritic destructive disease in the right subtalar joint. She cannot walk because of continuous pain in the ankle and foot. Any inversion or eversion causes immediate severe discomfort. According to the patient record review, the patient has had long-standing, severe osteoporosis and rheumatoid arthritis. In addition, she has been on long-term steroid therapy. The patient has spontaneously fractured ribs, with delayed healing.

PAST HISTORY
Medications: Long-term corticosteroid therapy for rheumatoid arthritis. Currently, prednisone 40 mg daily p.o.
Illnesses: Rheumatoid arthritis, osteoporosis.
ALLERGIES: NO ALLERGIES TO FOOD OR MEDICATION.
Social history: The patient was employed as a plumber until the age of 50 when progressive arthritis limited her ability to continue working.
Family history: There is no family history of cancer, diabetes. A paternal uncle and a sister have RA.

REVIEW OF SYSTEMS
Cardiorespiratory: Pleuritic pain and dyspnea and focal pain over the left 4th, 5th and 6th ribs began 1 week ago spontaneously. No history of trauma.

PHYSICAL EXAMINATION
GENERAL: This is a 60-year-old, 180-pound white female in moderate distress.
VITAL SIGNS: Pulse: 100 and regular. Blood pressure: 140/110. Respiratory rate: 20, guarded. Temperature: 99.6 °F.
CHEST: There is pinpoint tenderness over the left 4th, 5th and 6th ribs in the left midaxillary line. Heart: PMI left midclavicular line. Regular rate and rhythm without murmurs. Lungs: Clear.
NEUROLOGIC: There is a decrease in sensation in the right ankle and foot. Cranial nerves 2-12 are intact.

DATABASE
A bone survey shows diffuse, widespread changes of rheumatoid arthritis with destruction of taloscaphoid axis and pronation of the right foot. RF factor positive.

ASSESSMENT
1. Rheumatoid arthritis with severe destructive disease of the subtalar joint, right ankle and foot.
2. Spontaneous pathologic fractures, left ribs 4-6 due to osteoporosis.

RECOMMENDATIONS
The severe pain and limitation of motion of right foot argues in favor of triple arthrodesis with bone graft from the right iliac crest to the right subtalar joint and transfer of the peroneal tendons of the right ankle. It is well known that the patient has severe osteoporosis and spontaneously fractured ribs. However, because of the severity of the destruction of the right ankle, arthrodesis is recommended at this time. A written report will be sent to the referring physician.
Determine the level for the number and complexity of the problems addressed at the encounter in Scenario 1.
A.Minimal

B. Low

C. Moderate

D. High

Determine the level for the amount and/or complexity of data to be reviewed and analyzed in Scenario 1.

A.Minimal or None  B. Limited  C. Moderate  D. Extensive Determine the level for the risk of complications and/or morbidity or mortality of patient management in Scenario 1.

A.Minimal

B. Low

C. Moderate

D. High

Determine the level of medical decision making for Scenario 1.

A.straightforward

B. Low

C. Moderate

D. High