What would be missing from this H&P to move it from a 99222 to a 99223 ??
IMPRESSION:
1. Atypical chest pain of unclear etiology, rule out myocardial ischemia/musculoskeletal gastrointestinal/other.
2. Diabetes mellitus (hemoglobin A1c of 7.5).
3. Dyslipidemia.
4. Tobacco abuse.
5. Probable obstructive sleep apnea based on symptoms.
RECOMMENDATIONS:
1. The patient is chest pain-free and has had negative cardiac enzymes. We will obtain a Cardiology consult given multiple vascular risk factors and a premature history of coronary artery disease. The patient will require cardiac stress test.
2. In terms of the patient's diabetes, we will obtain a urinalysis for proteinuria. We will start glucose 850 mg p.o. at bedtime. For now, the patient has been counseled on the importance of diet and exercise. He will see the diabetic educator prior to discharge with appropriate instruction on monitoring blood sugars and follow up. He will be advised to see a podiatrist for diabetic foot care once a year and should obtain a diabetic bracelet. He will obtain a flu shot prior to discharge.
3. In terms of the patient's dyslipidemia, we will start Lopid Gemfibrozil 600 mg twice a day. We will obtain liver function testing in 1 month and monitor triglyceride level. If his triglycerides come down to an acceptable level and his LDL can be measured, he will very well likely be converted to a statin agent.
4. The patient has been advised to obtain an overnight polysomnogram for evaluation of obstructive sleep apnea in the outpatient setting.
5. The patient has been advised to quit smoking as this is perhaps one of the single best things he can do. Further recommendations as more details become available.
HISTORY OF PRESENT ILLNESS: The patient is a 40-year-old gentleman who was otherwise well until last evening at approximately 6:30 p.m. He is left-handed. While at work, he did develop pain in his left armpit which was described as stabbing, sharp, nonradiating that lasted for hours in the afternoon. He felt as if there was tingling in his left arm and that there was, "ice like feeling" in his left axilla. There was no associated palpitations, shortness of breath, cough, sputum production or emesis, no back pain.
It became associated with slight nausea, slight diaphoresis, cold and clammy sensation and the feeling of passing out. Because of this, he presented to the Emergency Room for evaluation.
In the Emergency Room, he was noted to be hypertensive and was anxious.
His blood pressure was 180/112. He was given labetalol intravenously, and his post-blood pressure recording was 140/90. The patient has had no major events overnight. He has no further pain in his left axilla. He denies recent neck pain, recent long car rides, recent unusual activity or lifting weights.
PAST MEDICAL HISTORY: He has no significant past medical history. He did have a cardiac stress test approximately 2 years ago in the Sacramento region as he does have a strong family history of coronary artery disease (see below).
ALLERGIES: He has no known drug allergies.
MEDICATIONS: He takes no medications.
FAMILY HISTORY: He has 2 brothers with premature coronary artery disease, one at 37 and one at 40.
SOCIAL HISTORY: He started smoking 1 week ago after abstaining for a period of 1 year. He did smoke 1 pack per day for a period of 10 years. He works in sales. He is married. He denies illicit substance abuse.
PHYSICAL EXAMINATION:
GENERAL: He is awake, alert, comfortable, appears his stated age. He is afebrile. Pulse rate is in the 70s, blood pressure is in the 120-130s/60s. Pulse oximetry is 99% on room air.
HEENT: Sclerae are anicteric, conjunctivae pink. Pupils equal, round, reactive to light. Mallampatti airway score is 3.
NECK: No neck masses or bruits, no supraclavicular adenopathy.
HEART: Sounds are regular rate and rhythm without added sounds.
LUNGS: Breath sounds are clear to auscultation without wheezes or crackles.
ABDOMEN: On palpation in the left axilla, I am unable to reproduce his pain that he complained of last evening.
ABDOMEN: Obese, soft, nontender with normoactive bowel sounds.
EXTREMITIES: Warm with adequate capillary refill. There is no clubbing, cyanosis or edema.
PERTINENT INVESTIGATIONS: An EKG obtained this morning demonstrates normal sinus rhythm without ST or T-wave change. The sodium is 144, potassium 3.7, BUN over creatinine is 11/0.9 glucose was initially 265 and is 131 this morning. Troponin I was negative for x2 sets. Liver function testing was within normal limits. INR was 0.9. Triglycerides 578, HDL 33, LDL was unmeasurable. Hemoglobin A1c 7.5, white blood cell count 6.7, hemoglobin 16.1, platelet count 250. Chest x-ray was normal.
ASSESSMENT AND PLAN: For full details regarding assessment and plan, please refer to page 1.
IMPRESSION:
1. Atypical chest pain of unclear etiology, rule out myocardial ischemia/musculoskeletal gastrointestinal/other.
2. Diabetes mellitus (hemoglobin A1c of 7.5).
3. Dyslipidemia.
4. Tobacco abuse.
5. Probable obstructive sleep apnea based on symptoms.
RECOMMENDATIONS:
1. The patient is chest pain-free and has had negative cardiac enzymes. We will obtain a Cardiology consult given multiple vascular risk factors and a premature history of coronary artery disease. The patient will require cardiac stress test.
2. In terms of the patient's diabetes, we will obtain a urinalysis for proteinuria. We will start glucose 850 mg p.o. at bedtime. For now, the patient has been counseled on the importance of diet and exercise. He will see the diabetic educator prior to discharge with appropriate instruction on monitoring blood sugars and follow up. He will be advised to see a podiatrist for diabetic foot care once a year and should obtain a diabetic bracelet. He will obtain a flu shot prior to discharge.
3. In terms of the patient's dyslipidemia, we will start Lopid Gemfibrozil 600 mg twice a day. We will obtain liver function testing in 1 month and monitor triglyceride level. If his triglycerides come down to an acceptable level and his LDL can be measured, he will very well likely be converted to a statin agent.
4. The patient has been advised to obtain an overnight polysomnogram for evaluation of obstructive sleep apnea in the outpatient setting.
5. The patient has been advised to quit smoking as this is perhaps one of the single best things he can do. Further recommendations as more details become available.
HISTORY OF PRESENT ILLNESS: The patient is a 40-year-old gentleman who was otherwise well until last evening at approximately 6:30 p.m. He is left-handed. While at work, he did develop pain in his left armpit which was described as stabbing, sharp, nonradiating that lasted for hours in the afternoon. He felt as if there was tingling in his left arm and that there was, "ice like feeling" in his left axilla. There was no associated palpitations, shortness of breath, cough, sputum production or emesis, no back pain.
It became associated with slight nausea, slight diaphoresis, cold and clammy sensation and the feeling of passing out. Because of this, he presented to the Emergency Room for evaluation.
In the Emergency Room, he was noted to be hypertensive and was anxious.
His blood pressure was 180/112. He was given labetalol intravenously, and his post-blood pressure recording was 140/90. The patient has had no major events overnight. He has no further pain in his left axilla. He denies recent neck pain, recent long car rides, recent unusual activity or lifting weights.
PAST MEDICAL HISTORY: He has no significant past medical history. He did have a cardiac stress test approximately 2 years ago in the Sacramento region as he does have a strong family history of coronary artery disease (see below).
ALLERGIES: He has no known drug allergies.
MEDICATIONS: He takes no medications.
FAMILY HISTORY: He has 2 brothers with premature coronary artery disease, one at 37 and one at 40.
SOCIAL HISTORY: He started smoking 1 week ago after abstaining for a period of 1 year. He did smoke 1 pack per day for a period of 10 years. He works in sales. He is married. He denies illicit substance abuse.
PHYSICAL EXAMINATION:
GENERAL: He is awake, alert, comfortable, appears his stated age. He is afebrile. Pulse rate is in the 70s, blood pressure is in the 120-130s/60s. Pulse oximetry is 99% on room air.
HEENT: Sclerae are anicteric, conjunctivae pink. Pupils equal, round, reactive to light. Mallampatti airway score is 3.
NECK: No neck masses or bruits, no supraclavicular adenopathy.
HEART: Sounds are regular rate and rhythm without added sounds.
LUNGS: Breath sounds are clear to auscultation without wheezes or crackles.
ABDOMEN: On palpation in the left axilla, I am unable to reproduce his pain that he complained of last evening.
ABDOMEN: Obese, soft, nontender with normoactive bowel sounds.
EXTREMITIES: Warm with adequate capillary refill. There is no clubbing, cyanosis or edema.
PERTINENT INVESTIGATIONS: An EKG obtained this morning demonstrates normal sinus rhythm without ST or T-wave change. The sodium is 144, potassium 3.7, BUN over creatinine is 11/0.9 glucose was initially 265 and is 131 this morning. Troponin I was negative for x2 sets. Liver function testing was within normal limits. INR was 0.9. Triglycerides 578, HDL 33, LDL was unmeasurable. Hemoglobin A1c 7.5, white blood cell count 6.7, hemoglobin 16.1, platelet count 250. Chest x-ray was normal.
ASSESSMENT AND PLAN: For full details regarding assessment and plan, please refer to page 1.