Chapter 19: CPT® Section Evaluation & Management Textbook Section 19B.1 Answers and Rationale.

Chapter 19: CPT® Section Evaluation & Management Textbook Section 19B.1 Answers and Rationale.

  1. Answer: A. Problem Focused
    Rationale: 1 element in HPI (Modifying Factor, No elements in ROS, and No elements in PFSH
    CC: Follow up of hospitalization for pneumonia.
    HPI: Modifying Factor – He was placed back on Singulair® and has been improving with his breathing since then.
    ROS: None
    PFSH: None -not required for an interval history
  2. Answer: C. Detailed
    Rationale: 4 elements in HPI, 2 elements in ROS, and 1 element in PFSH
    CC: Asthma exacerbation
    HPI: Duration—Two to three days
    Associated signs and symptoms-cough
    Quality—Productive cough
    Severity—Getting worse
    ROS: Constitutional—Denies fever or chills
    Respiratory—Difficulty breathing
    PFSH: Past History—Currently uses inhalers (current medication)
  3. Answer: B. Expanded problem focused
    Rationale: 3 elements in HPI, 1 element in ROS, 3 elements in PFSH
    CC: Skin lesions
    HPI: Location—Forehead and lateral to right eye
    Duration—About a year
    Associated Signs & Symptoms—another skin lesion lateral to right eye
    ROS: Integumentary—No other skin complaints
    Stated, “Otherwise well,” but this is not an indication that all other systems were reviewed.
    PFSH: Past, Family, and Social all reviewed as it relates to skin.
  4. Answer: D. Comprehensive
    Rationale: 4 elements in HPI, Complete ROS, Complete PFSH
    CC: Fever
    HPI: Duration—Less than one day
    Severity—High fever
    Associated signs and symptoms—Decreased appetite
    Modifying factor—Tylenol has been given which reduced the fever
    ROS: GI—No vomiting or diarrhea
    Resp—Parents unaware of any cough
    Rest of review of systems reviewed and negative: Complete ROS
    PFSH: Personal history—Current meds
    Social history—Not exposed to second hand smoke
    Family History—Mother is an asthmatic.
  5. Answer: B. Expanded Problem focused
    Rationale: 2 elements in HPI, 3 elements in ROS, 2 elements in PFSH
    CC: ATV accident
    HPI: Context—ATV accident
    Location—Lip and chin lacerations
    ROS: GI—Negative for nausea and vomiting
    Eyes— Negative for blurred vision
    Neuro—Negative for headache
    PFSH: Past history—surgeries and illnesses reviewed, current meds
    Social history—Nonsmoker, moderate alcohol
    Note: Only 2 of 3 PFSH are needed for complete for Emergency Department, but all three are needed for a complete PFSH for a hospital admit.