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based on calculator, thats a tenuous level 5. seems level 4 is more appropriate.Patient this morning, referred for back pain, typical multilevel degenerative changes on MRI. Noted short of breath walking the 200 ft or so from reception to exam room, with no know cardiac or pulmonary diagnoses. Mild anemia (likely iron deficiency) on labs sent from PCP, last colonoscopy 20 years ago, bilateral pitting edema, and early systolic murmur, grade 2. Also DM2, not controlled. For the back I recommended PT, but I’m sending her back to her PCP for possible cardiology and GI referrals. Level 5.
Problem/diagnosis: 1 or more chronic illness with severe exacerbation, progression, or side effects.
Data: Extensive: labs, MRI report, review of PCP notes, plus personal review of MRI.
Treatment: debatable. Recommending consults that will lead to invasive tests. Discussed possible injection options for spine. But only ordered PT. Probably call it moderate risk overall.
its a sick patient, but you really only offered PT.
im not sure that sending back to PCP is enough.
you have level 5 in terms of medical problems, but level 4 moderate complexity, and at best level 4 moderate risk of treatment.
fwiw, i have a hard time justifying the above case as a level 5 when i see at least 4-5 patients with like symptoms daily..