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How would you code the following service:
Subjective: No acute events overnight, no complaints this a.m.
Vital Signs
Heart Rate Monitored 75 bpm Normal
Respiratory Rate 13 br/min Normal
Pulse Ox Sat 96 %
NIBP Systolic 142 mmHg
NIBP Diastolic 78 mmHg
NIBP Mean Calculated 99 mmHg
NIBP Mean Monitored 97 mmHg
Temperature Oral 97.9 DegF Normal
FiO2 28 %
Oxygen Modality Trach Collar with Humidification
Gen.: No acute distress
Respiratory: Clear to auscultation bilaterally
Cardiovascular: Regular rate and rhythm, no murmurs appreciated on exam, 2+ radial pulses bilaterally
GI: Obese, soft, nontender, nondistended, normoactive bowel sounds present throughout
Impression and Plan
Patient with PMHx of MG diagnosed in (year), previous TIA, diabetes, gastroparesis, hyperlipidemia, cardiomyopathy on MICU day 2 for MG crisis
Neuro
1. MG
- Reported history of MG that was diagnosed in (year), sees Dr. neurologist
- On Cellcept 500mg BID, Pyridostigmine 60mg QID, and Prednisone 10mg qd at home
- Neurology was consulted, appreciate input. Patient underwent one round of plasmapheresis on (date), next session scheduled for tomorrow (date)
- Given reported improvement after one round of plasmapheresis, neurology does not believe patient would require the full 5 rounds, we will monitor following session tomorrow
- Per neurology, recommended increasing Prednisone to 20 mg daily. Continue Cellcept at 500mg BID. Pyridostigmine at 120mg qam f/b 60mg TID.
- Note, tried contacting Dr. neurologist's office today, no response. Will try again in the a.m.
- PT/OT consulted, appreciate input
Cardiovascular
1. History of cardiomyopathy
- Underwent a cardiac stress test in (date) that showed no EKG changes consistent with ischemia. Recent echo on showed EF 65%, normal LV systolic function, grade 1 diastolic dysfunction, no significant valvular or wall motion abnormalities.
- Reports being on Lasix at home, holding at this time
Pulmonology
1. Asthma
- Continue Xopenex, Pulmicort
2. Chronic tracheostomy
- Will place on home vent settings overnight
No ID, renal, GI, or hematologic issues.
Endocrine
1. T2DM
- Per chart review, on Glargine 15U qd, Humalog 9U TID/ac
- Will start on Glargine 10U qd, Novolog 5U TID/ac, SSI.
- Monitor glucose and adjust accordingly
FEN/GI: Regular diet
DVT ppx: Lovenox 40mg SC qd
Lines: Trach, PIV, RIJ
Code status: Full code
Dispo: Transfer in the a.m.
(Resident Signature)
Attending Note
I examined the patient with the Medical Intensive Care Unit teaching service. I have reviewed the available laboratory and imaging data, as well as the recommendations of any consulting physicians. This patient is critically ill with a high risk of organ system dysfunction or failure and currently requires intensive monitoring, frequent reassessment, and medical care.
Assessment and Plan of Care:
1. Chronic respiratory failure: will use home Trilogy vent at night and as needed. Since patient has a tracheostomy and a home vent, serial NIF/FVC measurements are not needed.
2. Myasthenic crisis: thought to be due to new med (torsemide). On PLEX--has received one treatment. Neurology recommendations noted. Patient has had multiple CT scans of the chest, which show no thymoma. Patinet has also been worked up extensively in the past and I don't think we need to repeat all of the diagnostic testing.
3. H/O cardiomyopathy: compensated at this time.
4. DM: will use SSI to keep glucose < 200.
I have spent at least 30 minutes providing critical care services to this patient. This time includes bedside assessments; reviewing data; discussion with consulting physicians, nursing staff, respiratory therapists, and pharmacists; family discussions; and documentation. It does not include time spent teaching or performing separately billable procedures.
(Attending Signature)
Subjective: No acute events overnight, no complaints this a.m.
Vital Signs
Heart Rate Monitored 75 bpm Normal
Respiratory Rate 13 br/min Normal
Pulse Ox Sat 96 %
NIBP Systolic 142 mmHg
NIBP Diastolic 78 mmHg
NIBP Mean Calculated 99 mmHg
NIBP Mean Monitored 97 mmHg
Temperature Oral 97.9 DegF Normal
FiO2 28 %
Oxygen Modality Trach Collar with Humidification
Gen.: No acute distress
Respiratory: Clear to auscultation bilaterally
Cardiovascular: Regular rate and rhythm, no murmurs appreciated on exam, 2+ radial pulses bilaterally
GI: Obese, soft, nontender, nondistended, normoactive bowel sounds present throughout
Impression and Plan
Patient with PMHx of MG diagnosed in (year), previous TIA, diabetes, gastroparesis, hyperlipidemia, cardiomyopathy on MICU day 2 for MG crisis
Neuro
1. MG
- Reported history of MG that was diagnosed in (year), sees Dr. neurologist
- On Cellcept 500mg BID, Pyridostigmine 60mg QID, and Prednisone 10mg qd at home
- Neurology was consulted, appreciate input. Patient underwent one round of plasmapheresis on (date), next session scheduled for tomorrow (date)
- Given reported improvement after one round of plasmapheresis, neurology does not believe patient would require the full 5 rounds, we will monitor following session tomorrow
- Per neurology, recommended increasing Prednisone to 20 mg daily. Continue Cellcept at 500mg BID. Pyridostigmine at 120mg qam f/b 60mg TID.
- Note, tried contacting Dr. neurologist's office today, no response. Will try again in the a.m.
- PT/OT consulted, appreciate input
Cardiovascular
1. History of cardiomyopathy
- Underwent a cardiac stress test in (date) that showed no EKG changes consistent with ischemia. Recent echo on showed EF 65%, normal LV systolic function, grade 1 diastolic dysfunction, no significant valvular or wall motion abnormalities.
- Reports being on Lasix at home, holding at this time
Pulmonology
1. Asthma
- Continue Xopenex, Pulmicort
2. Chronic tracheostomy
- Will place on home vent settings overnight
No ID, renal, GI, or hematologic issues.
Endocrine
1. T2DM
- Per chart review, on Glargine 15U qd, Humalog 9U TID/ac
- Will start on Glargine 10U qd, Novolog 5U TID/ac, SSI.
- Monitor glucose and adjust accordingly
FEN/GI: Regular diet
DVT ppx: Lovenox 40mg SC qd
Lines: Trach, PIV, RIJ
Code status: Full code
Dispo: Transfer in the a.m.
(Resident Signature)
Attending Note
I examined the patient with the Medical Intensive Care Unit teaching service. I have reviewed the available laboratory and imaging data, as well as the recommendations of any consulting physicians. This patient is critically ill with a high risk of organ system dysfunction or failure and currently requires intensive monitoring, frequent reassessment, and medical care.
Assessment and Plan of Care:
1. Chronic respiratory failure: will use home Trilogy vent at night and as needed. Since patient has a tracheostomy and a home vent, serial NIF/FVC measurements are not needed.
2. Myasthenic crisis: thought to be due to new med (torsemide). On PLEX--has received one treatment. Neurology recommendations noted. Patient has had multiple CT scans of the chest, which show no thymoma. Patinet has also been worked up extensively in the past and I don't think we need to repeat all of the diagnostic testing.
3. H/O cardiomyopathy: compensated at this time.
4. DM: will use SSI to keep glucose < 200.
I have spent at least 30 minutes providing critical care services to this patient. This time includes bedside assessments; reviewing data; discussion with consulting physicians, nursing staff, respiratory therapists, and pharmacists; family discussions; and documentation. It does not include time spent teaching or performing separately billable procedures.
(Attending Signature)