Patient Consultation and Reconstructive Surgery Discussion: Case Study Analysis

QUESTION

Patient:  Jane Smith

DOS:  5/1/xx

Chief Complaint:

Jane Smith is a 55-year-old female presenting for a consultation today to discuss reconstructive surgery.  She recently had a mastectomy and axillary lymph node removal. She was referred to me by her Oncologist, Michael Wells, MD.

Her diagnosis is Post Mastectomy for recurring LUQ Breast Cancer.

Family Medical History: 

Mother- history of breast cancer

Father- none

Review of Systems:

Constitutional: She is experiencing low energy and fatigue post-operatively.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
Skin: She stated her incisions are healing nicely, and her drains were recently taken out by Dr. Wells.
Cardiovascular: No chest pain, chest pressure, or chest discomfort. No palpitations or edema. She is currently on Lisinopril for HTN.
Respiratory: No shortness of breath, cough, or sputum.
Gastrointestinal: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
Neurological: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
Musculoskeletal: No muscle, back pain, joint pain, or stiffness.
Hematologic: No anemia, bleeding, or bruising.
Lymphatics: No enlarged nodes. No history of splenectomy.
Psychiatric: Currently on Zoloft.

Endocrinologic: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
Allergies: No history of asthma, hives, eczema, or rhinitis.

Assessment and Plan: 

General Appearance: Well-nourished female in no acute distress.  Vital Signs: Blood pressure 112/72, pulse rate 63 beats per minute, temperature 98.4 degrees Fahrenheit, SpO2 saturation 99%, weight 163 lbs.  I spent 20 minutes discussing Jane her options and breast reconstruction.  We discussed immediately versus delayed reconstruction.  We also discussed different types of reconstruction, from tissue expander/implant-based to autologous reconstruction.  I informed her of the expectations, outcomes, length of hospital stay, and recovery associated with each procedure.  I discussed the advantages and disadvantages of each.

At this point, Jane feels uncomfortable proceeding with any reconstruction, understanding that delayed reconstruction would be the only option since she is not ready to proceed.  The patient is okay with that and will contact the office if she chooses to pursue delayed reconstruction. We also discussed her post-op fatigue, and I recommend a B-12 injection to see if that helps.  Jane consented to have a B-12 injection today. I also informed her that she should follow up with her PCP if the fatigue continues.

I appreciate the opportunity to evaluate Ms. Smith.

30 minutes total time spent with the patient.

Electronically Signed By:

Craig Scott, MD 5/1/xx 12:50 pm

Copy of encounter sent to requesting physician, Dr. Michael Wells
Craig Scott, MD 5/1/xx 12:50

PROCEDURE NOTE:

Prepping the left arm, I injected 1000mcg Cyanocobalamin, IM into her left arm deltoid muscle, upper left arm. I had the patient wait in the exam room for 15 minutes to ensure no adverse reactions.

The patient tolerated the injection well.

Instructions were provided to the patient to follow up with primary care.

Mary Ross, RN 5/1/xx  12:55
Provide CPT Evaluation and Management (E/M) Code:

Provide CPT Procedure Codes for Office Procedure (s):

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ANSWER

Patient Consultation and Reconstructive Surgery Discussion: Case Study Analysis

Introduction

This case study centers around Jane Smith, a 55-year-old female who recently underwent a mastectomy and axillary lymph node removal due to recurring LUQ breast cancer. The patient’s chief complaint involves a consultation to discuss reconstructive surgery options. This paper aims to analyze the patient’s medical history, review of systems, assessment, plan, and procedure notes provided by the healthcare professionals involved in Jane’s care.

Medical History and Assessment

Jane’s medical history reveals a family predisposition to breast cancer through her mother. The review of systems highlights post-operative fatigue and low energy. Her vital signs indicate stability, and she is in no acute distress. The assessment discusses the extensive consultation that took place, explaining various breast reconstruction options, immediate versus delayed procedures, and the advantages and disadvantages of each. Jane’s decision to postpone reconstruction is respected, and her post-operative fatigue is addressed with a recommended B-12 injection.

Path to Recovery and Interventions

The procedure note outlines the administration of a 1000mcg Cyanocobalamin injection into Jane’s left arm deltoid muscle. The patient’s tolerance to the injection is well-documented, and a 15-minute observation period is implemented to ensure her safety. Instructions are given for follow-up with her primary care provider.

Social Determinants of Health

Considering the case from a social determinant of health perspective, it is evident that Jane’s family history of breast cancer could impact her perception of health and influence her decision-making process. Factors such as genetics, access to healthcare resources, and psychological well-being may interplay in shaping her healthcare choices. Ensuring equitable access to information, support, and healthcare services is vital in addressing these determinants and optimizing her overall care experience.

Discussion and Conclusion

The healthcare team’s comprehensive approach to Jane’s care is evident in the detailed assessment, personalized treatment plan, and consideration of her preferences. The patient’s autonomy is respected, and interventions are tailored to her needs, emphasizing the patient-centered care approach. Furthermore, the procedure note highlights the careful administration of the B-12 injection, ensuring patient safety.

In conclusion, Jane Smith’s case exemplifies the importance of effective communication, informed decision-making, and individualized care in oncological settings. The provided medical records showcase a collaborative effort to address Jane’s needs and concerns, while also highlighting the significance of social determinants of health. By integrating medical expertise, patient preferences, and equitable care principles, healthcare professionals contribute to the comprehensive well-being of patients like Jane, enhancing their overall quality of life and health outcomes.