2nd Set of Cases
For
Basic Inpatient E/M Training
INPATIENT CODING FEE TICKETS
COVER SHEET
Provider Name:Department:
Contact Info:
Please return the
Six coded procedure and Six coded diagnosis
fee tickets
with this coversheet to:
UT Medicine
Attention: Diane McEntire
Phone: 210-257-1408
or
Via Email:
or
Via Fax: 210-257-1421
Case #1: Consultation
CC: left hip pain
HPI: This is an 88 y/o female with long h/o Alzheimer’s dementia thatfell at home after reportedly getting dizzy, but no loss of consciousness. Per her daughter, over the last several months mother’s dementia has worsened; otherwise doing well. Asked by Dr. Brown, Orthopaedics, for a pre-operative evaluation of this patient who is scheduled for surgical repair of a closed left femur fracture.
Hx: Past Medical/Surgical: Hypertension, no drug allergies, no prior surgeries. Medications: namenda 10mg twice a day, exelon 4.6mg/24hr patch daily, diovan 160mg daily
Social: no tobacco, etoh, or drugs. Family: sister deceased had hypertension
Review of Systems:
Constitutional: No fevers, chills or weight loss. Eyes: No icterus or visual changes. Cardiovascular: No chest pain or palpitations. Respiratory: No shortness of breath or cough. Genitourinary: No dysuria. Hematology/Lymph: No bruising or petechiae. Musculoskeletal: No pain except left hip pain. Psychiatric: No auditory or visual hallucinations. Neurologic: No numbness or headaches.
Examination: Vital Signs: BP: 174/72, Pulse 78, Resp Rate 14, Temp 98.1, Oxygen Saturation 97% RA. General: Alert and oriented to person only. Eyes: Extra ocularmovements intact;pupils equal, round, and reactive to light. HEENT: Oropharynx clear, nasal passages clear. Neck: Supple, no carotid bruits, no jugular venous distension. Cardiac: Regular, rate, S4, no murmurs, rubs or gallops. Lungs: Clear to auscultation bilaterally,good air movement throughout. Abdomen/GI: soft, non-tender, non-distended, +bowel sounds. Extremities: 5 out of 5 strength in all four extremities except she cannot move LLE due to pain, no clubbing, cyanosis, or edema, 1+ distal pedal pulses. Back: No costovertebral or vertebral tenderness to palpation. GU: Deferred. Neurologic: Cranial nerves 2-12 are grossly intact, 1+ deep tendon reflexes in bilateral patellar and brachial tendons, gross sensation is intactthroughout.
Reports reviewed:EKG: Normal sinus rhythm, no acute ST changes, normal intervals. CXR: No acute infiltrates, masses or effusions. Hip film: left femoral neck fracture.Labs:hct 31; cr 1.2; CO2 30; BUN 33
A/P:
1)Alzheimer's dementia: stable, would continue on Namenda and Exelon
2)Hypertension: continue diovan. May consider addition of beta blockers if pain control doesn't improve blood pressure.
3)Closed left femoral neck fracture: From a cardiac standpoint, she is moderate risk for a moderate risk surgery. Would not recommend any further non-invasive studies prior surgery. From a pulmonary standpoint, she is moderate risk, would perform aggressive pulmonary toilet with IS post-op. From a deep vein thrombosis standpoint, she is high risk and would start fondaparinox. From a delirium standpoint, she is high risk and would give haldol 2.5mg as needed for agitation if not redirectable first. Discussed recommendations with Dr. Brown who requested Medicine continue to follow patient for Alzheimer's dementia and hypertension.
Case # 2: Hospital Discharge
CC:Acute duodenal ulcer
Three days ago, 41 y/o male presented to the Emergency department and was admittedwith complaints of mid-epigastric pain that progressively worsened over 2 weeks after initiating acetylsalicylic acid as instructed by his doctor forapparent transient ischemic attack/cerebrovascular accident.CXR, KUB,CT abdomen & pelvis, right upper quadrant sonowere all normal. Pt improved after nothing by mouth overnight, and then gradually advanced to clear liquid diet and then low fat solid diet and tolerated well. He reported one bloody stoolas there was concern forgastritis given history of aspirin use (pt reportedtaking 2 tablets-dose unknown-3 to 4 times a dayfor a few weeks prior to admission). Esophagogastroduodenoscopy showed ulcer induodenum bulb without hemorrhage or obstruction. Hemoglobin and hematocrit within normal limits and stable during entire hospital stay.
Examination: No acute distress; Abdomen: non-tender/non-distended, normal bowel sounds.
Discharge Instructions: Patient given prescription for Prevacid 30 mg oral delayed release capsule. Discussed at length hospital stay and test findings and prognosis, and instructions tofollow-up with his physician for management ofTIA/CVA as aspirin is now contraindicated in setting of peptic ulcer disease. Avoid nonsteroidal anti-inflammatory drugs and high fat diet.
Total time to discharge patient 45 minutes.
Case# 3: Admit H & P
CC: Progressive shortness of breath with fever and nasal secretions
HPI: 52 y/o femaleadmitted electively to evaluate progressively worseningshortness of breathover the past month, dyspnea on exertion, and recent fever/chills and nasal secretion. Patient also has some pleuritic chest pain and a few acute episodes of confusion withdesaturation. Oxygen saturation in clinic was 88.
ROS: Cardiovascular: No chest pain or palpitations. Pulmonary: As above. GI: No nausea, vomiting, diarrhea, or constipation. GU: No dysuria. Hematology: No bruising or petechiae. Musculoskeletal: No arthralgias or myalgias. Psychiatric: No suicidal or homicidal ideations, no auditory or visual hallucinations.Neurologic: No dysarthria, dysphagia or headaches or visual changes
Hx:
Past Medical/Surgical: Pneumonia; Ovarian Carcinoma - treatment completed x 2 years. Family: Father - Prostate CA.
Social: Denies etoh or drug use, smokes occasionally.
Medications: Ambien 10mg at bedtime, Norco 10/325mg every 6 hours as needed; Prednisone 60 mg daily.
Examination:
Temperature:97.4BP: 126/76HR: 94RR: 18O2:99 on room air
GEN: Alert and oriented to person, place or time no acute distress, conversational dyspnea. No accessory muscle use.HEENT: pupils equal, round, and reactive to light;mouth moist mucous membrane.NECK: No JVD, no carotid bruits. CV: regular rate and rhythm. PULM: Bibasilar rales.ABD: Soft, non-tender, non-distended, no hepatosplenomegaly +bowel soundspresent. EXT: 2+ distal pulses, no edema. Clubbed fingers. NEURO: Strength and sensation grossly intact, Cranial nerves 2-12 intact.DERM: No rashes.
Report Reviewed: Significant for the following:CBC: 17.1 / 11.7 / 35.5 / 381, CHEM10: 141 / 3.7 / 106 / 32 / 13 / 0.9 / 105. Order - CXR & EKG. Repeat PFTs.
A/P:
Progressive shortness of breath – differential diagnosis includes non-specific interstitial pneumonia, pulmonary edema, or acute respiratory infection. Broad spectrum antibiotics with Vanc/Cefepime. Cultures taken, awaiting results. StartPrednisone 60mg daily. Nothing by mouth after midnight for bronchoscopy in the morning. Oxygen by nasal cannula to keep sats > 93%. Lasix for volume overload issues.
Disposition: Admit to Medicine
Case# 4: Subsequent Hospital Visit – Day 2
Interval History: The patient is a 67 y/o male who was admitted after an acute stroke. Patient developed slurred speech overnight.
Examination:
Vitals: 97.2 75 131/71 20 99%
GEN: no acute distress, Alert and oriented to person and place
HEENT: pupils equal, round, and reactive to light, extraocular movement are intact,speech impaired.
NEURO: cranial nerves 2-12 appear intact except now with right facial paralysis. 5/5 strength bilateral upper and lower extremities
Labs Reviewed:
CBC 6.2/10.6/31.1/207
Chem 140/3.6/107/25/21/0.8/94 9.1/2.0/3.6
Assessment/Plan:
1)Cerebrovascular accident due to left middle carotid artery infarct.
2)Magnetic resonance imaging and Magnetic resonance arteriography show left carotid stenosis. Consult request to Vascular Surgery for evaluation and treatment options. For his underlying coronary artery disease, we will restart his low dose metoprolol and continue Lipitor and aspirin.
Case#5: Initial Observation Service
C/C: Chest pain
HPI: Pt is a 56 y/o female placed underobservation at 1500today(1/9)for work up for chest pain. Pt reports having chest pressure that woke her up from sleep; had associated sweats and chills. Pt reports relief of the pressure with nitroglycerin. Chest pressure relieved by nitroglycerin patch received in Emergency department earlier today. Patient also received famotidine, aspirin, and was started on normal saline 200cc/hr.
ROS: Gen: denies fever/chills. Skin: no rashes or lesions. HEENT: no visual or hearing changes,epistaxis,or sore throat. Lymph:no swollen glands. CV: denies palpitations.Resp: denies shortness of breath. GI: denies nausea/vomiting/diarrhea /constipation. GU: no frequency, urgency or nocturia. Endocrine: no heat/cold intolerance. Neurologic: no tingling, numbness, weakness,or blackouts. Hematologic: does not bruise easily, no bleeding, MS: denies muscle weaknessor pain,joint stiffness
Hx: Past Medical/Surgical - as above. Metoprolol 100 mg bid, Motrin 800 mg.
Family – no h/o myocardial infarction.
Social:Occupation: has not worked for many years, lives with Husband in SA, does not smoke or use ETOH.
VITALS: Temp: 97.3 BP: 143/70 HR: 57 RR: 18 O2Sats: 97 % room air
Examination: Gen: no acute distress, cooperative .speaking in full sentences
HEENT: mucous membranes moist, pupils equal, round, and reactive to light and accomodation, neck supple, NO JVD; HEART: Bradycardic S1S2, no murmurs, rubs, and gallops appreciated; Resp: clear to auscultation bilaterally; Abd: Soft, non-tender, non-distended, bowel sounds positive, no organomegaly, no guarding , rebound or shifting dullness ,no CVA tenderness; Ext: No clubbing, cyanosis or edema, pulses 2 + bil.Neuro: MS: alert and oriented to person, time, and place, cranial nerves II-XII intact, grossly nonfocal; Motor: Good muscle tone, grossly 5/5 strength in all four extremities
Reports Reviewed: Electrocardiography: sinus bradycardia, no infarct/ischemia/hypertrophy. CXR: No focal opacity, pleural effusion, pneumothorax or other abnormalities.
Cardiac enzymes x 1 negative.
CBC with platelet and differential panel and Chem 7 Panel - ordered.
Assessment/Plan:
1)Chest pain - patient with multiple risk factors for Coronary artery disease.Pharmacological cardiovascular stress test ordered.
2)Hypertension -uncontrolled. Patient to continue metoprolol 100 mg bid.
Disposition: Pending results of stress testmay discharge in am (1/10).
Case# 6: Subsequent Hospital Visit
Interval history: 59 y/o male admitted 1 day ago for weakness found to be hypoglycemic. He has been taking food by mouth with little difficulty. This morning he has no new complaints. Point-of-care glucose range 86/107.
Examination:Vitals: 98.5, 18, 97%, 75, 125/76
General: no acute distress, alert and oriented x3, cachectic male, extremely thin man with severe temporal wasting. On the scale today standing patient weighs 109.5lbs
Heart: regular, rate and rhythm
Lungs: clear to auscultation bilaterally
Abdomen: mildly distended; + bowel sounds
Ext: 2+ pedal pulses, no edema
Labs Reviewed: cbc 4/10/30/225. bun/cr 7/0.2. albumin 2.2
A/P:
1)Hypoglycemia/malnutrition - patient tolerating by mouth nutrition. Will push supplements and between meal snacks.
2)Cachexia - physical therapy reported patient needed total support to stand and was quickly out of breath at 25 feet of ambulation. He needs full assistance to travel a short distance of about 5-10 feet.
27 of 35 minutes spent discussing patient’s condition and prognosis with familyand that patient will need continued nutritional monitoring. Discussed need to find a skilled nursing facility as family states they are unable to care for him at this time. Will get case managementinvolved in assisting with locating a skilled nursing facility for patient transfer in 1-2 days.