kmuerth
Networker
Upper management wants to code this as 99215. Do you agree?
CURRENT DIAGNOSES
1. Hypothyroidism,unspecified
2. Diabetes Mellitus-NIDD
3. Hyperlipidemia
4. Hypertension-Essential (Benign)
5. CAD, native coronary artery
6. Arrhythmia-Paroxysmal Atrial Fibrillation
7. Peripheral Vascular Disease
8. Bioprosthetic AVR/Maze procedure and ascending aortic repair 2004
____________________________
ALLERGIES
NKDA
____________________________
MEDICATIONS
1. metformin 1,000 mg tablet, 1 p.o. b.i.d.
2. Lantus 100 unit/mL Solution, 13 units SC qHS
3. levothyroxine 25 mcg capsule, 1 p.o. daily
4. atorvastatin 20 mg tablet, 1 p.o. daily
5. aspirin 81 mg tablet, chewable, 2 p.o. daily
6. Vitamin D3 1,000 unit capsule, 1 p.o. b.i.d.
7. Vitamin B-12 2,500 mcg tablet, sublingual, 1 p.o. daily
8. ferrous sulfate 325 mg (65 mg iron) tablet,delayed release (DR/EC), 1 p.o. daily
9. CoQ-10 100 mg capsule, 1 p.o. daily
10. multivitamin tablet, 1 p.o. daily
11. warfarin 2.5 mg tablet, 1 p.o. daily Su-M-W-Th-F, take 3.75mg on Tu and Sa
12. Amaryl 2 mg tablet, 1 p.o. b.i.d.
13. digoxin 125 mcg tablet, 1 p.o. daily for 1 month
14. diltiazem ER 240 mg capsule,extended release, 1 by mouth in the morning
15. losartan 100 mg tablet, 1 by mouth daily
16. propafenone 225 mg tablet, 1 by mouth every 8 hours
____________________________
CHIEF COMPLAINTS
1. Followup of Arrhythmia-Paroxysmal Atrial Fibrillation
2. Followup of CAD, native coronary artery
____________________________
HISTORY OF PRESENT ILLNESS
pt is a very pleasant 78-year-old seasonal visitor from Iowa.
She has paroxysmal atrial fibrillation controlled on Rythmol with Coumadin followed in Iowa, predominant sinus rhythm, peripheral vascular disease with left sided popliteal stent June 2010 with subsequent restenting, type 2 diabetes in 2002, hyperlipidemia, hypertension, bioprosthetic aortic valve replacement in June 2004 with a maze procedure and aortic valve reconstruction and nonobstructive coronary disease as noted then.
No shortness of breath or chest discomfort noted. She had a negative PET nuclear stress test last year.
________________________
PAST HISTORY
Past Medical Illnesses:
DM, hyperlipidemia, hypertension, hypothyroidism, PVD
Past Cardiac Illnesses:
atrial fibrillation, CAD, aortic valve disorder, mitral regurgitation
Surgical Procedures:
AVR tissue June 2004
Cardiology Procedures-Invasive:
multiple cardioversions for afib, cardioversion for afib January 2014
Cardiology Procedures-Noninvasive:
holter monitor 2005, TEE January 2014, Cardiac PET-Lexiscan January 2014
Peripheral Vascular Procedures:
Lt popliteal stent June 2010 and re-stent again
LVEF of 80% documented via Cardiac PET on 01/23/2014
____________________________
___
FAMILY HISTORY
Father -- No relevant family history
CARDIAC RISK FACTORS
Tobacco Abuse: negative; Family History of Heart Disease: negative; Hyperlipidemia: positive; Hypertension: positive; Diabetes Mellitus: positive
____________________________
SOCIAL HISTORY
Alcohol Use - does not use alcohol; Smoking - never smoked;
____________________________
REVIEW OF SYSTEMS
General
denies recent weight loss, weight gain, fever or chills or change in exercise tolerance.
Integumentary
denies any change in hair or nails, rashes, or skin lesions.
Eyes
denies diplopia, history of glaucoma or visual field defects.
Ears, Nose, Throat, Mouth
denies any hearing loss, epistaxis, hoarseness or difficulty speaking.
Respiratory
denies dyspnea, cough, wheezing or hemoptysis.
Cardiovascular
denies chest pain, palpitations, or shortness of breath.
Abdominal
denies ulcer disease, hematochezia or melena.
Musculoskeletal
denies any history of venous insufficiency, arthritic symptoms or back problems.
Neurological
denies any history of recurrent strokes, TIA, or seizure disorder.
Psychiatric
denies any history of depression, substance abuse or change in cognitive functions.
Endocrine
denies any history of heat/cold intolerance, polydipsia, or polyuria
Hematological/Immunologic
denies any food allergies, seasonal allergies, bleeding disorders.
____________________________
PHYSICAL EXAMINATION
VITAL SIGNS:
Blood Pressure:
142/64Sitting, Right arm, regular cuff
Height- 66"
Weight- 132.00 lbs.
Pulse- 80/min. Regular
CONSTITUTIONAL
cooperative, alert and oriented,well developed, well nourished, in no acute distress.
SKIN
warm and dry to touch, no apparent rash.
HEAD
normocephalic, normal hair pattern, no masses or tenderness
EYES
EOMS Intact,pupils equal and round, conjunctivae and lids grossly normal. No icterus.
ENT
ears, nose and throat reveal no gross abnormalities.
NECK
no palpable masses or adenopathy, no thyromegaly, no JVD, carotid pulses are full and equal bilaterally without bruits.
CHEST
normal symmetry, no tenderness to palpation, normal respiratory excursion, no intercostal retraction, no use of accessory muscles, normal diaphragmatic excursion, clear to auscultation.
CARDIAC
soft grade 1/6 systolic ejection murmur
ABDOMEN
abdomen soft, bowel sounds normoactive, no masses, no hepatosplenomegaly, non-tender, no bruits
PERIPHERAL PULSES
the femoral, popliteal, dorsalis pedis, and posterior tibial pulses are full and equal bilaterally with no bruits auscultated.
RECTAL
deferred.
EXTREMITIES & BACK
no deformities, clubbing, cyanosis, erythema or edema observed. Good muscle strength and tone.
LYMPHATICS
no cervical adenopathy.
PSYCHIATRIC
oriented to time, person and place. Affect appropriate.
NEUROLOGICAL
no gross motor or sensory deficits noted, No difficulties with speech or language, oriented to time, person and place.
____________________________
MEDICATIONS UPDATED TODAY:
____________________________
IMPRESSIONS/PLAN
1. Hypothyroidism/medical therapy
2. Diabetes under control
3. Hyperlipidemia
4. Hypertension under control
5. Paroxysmal atrial fibrillation with predominance sinus rhythm. Medicines as above
6. Lower extremity peripheral vascular stenting as above
7. Status post bioprosthetic aortic valve replacement/Maze procedure/ascending thoracic aneurysm repair in 2004.
EKG normal sinus rhythm at 90 beats minute, first-degree AV block, nonspecific ST-T wave abnormalities.
I will see her in one year for review.
____________________________
TODAYS ORDERS:
1. Return Visit 1 year
CURRENT DIAGNOSES
1. Hypothyroidism,unspecified
2. Diabetes Mellitus-NIDD
3. Hyperlipidemia
4. Hypertension-Essential (Benign)
5. CAD, native coronary artery
6. Arrhythmia-Paroxysmal Atrial Fibrillation
7. Peripheral Vascular Disease
8. Bioprosthetic AVR/Maze procedure and ascending aortic repair 2004
____________________________
ALLERGIES
NKDA
____________________________
MEDICATIONS
1. metformin 1,000 mg tablet, 1 p.o. b.i.d.
2. Lantus 100 unit/mL Solution, 13 units SC qHS
3. levothyroxine 25 mcg capsule, 1 p.o. daily
4. atorvastatin 20 mg tablet, 1 p.o. daily
5. aspirin 81 mg tablet, chewable, 2 p.o. daily
6. Vitamin D3 1,000 unit capsule, 1 p.o. b.i.d.
7. Vitamin B-12 2,500 mcg tablet, sublingual, 1 p.o. daily
8. ferrous sulfate 325 mg (65 mg iron) tablet,delayed release (DR/EC), 1 p.o. daily
9. CoQ-10 100 mg capsule, 1 p.o. daily
10. multivitamin tablet, 1 p.o. daily
11. warfarin 2.5 mg tablet, 1 p.o. daily Su-M-W-Th-F, take 3.75mg on Tu and Sa
12. Amaryl 2 mg tablet, 1 p.o. b.i.d.
13. digoxin 125 mcg tablet, 1 p.o. daily for 1 month
14. diltiazem ER 240 mg capsule,extended release, 1 by mouth in the morning
15. losartan 100 mg tablet, 1 by mouth daily
16. propafenone 225 mg tablet, 1 by mouth every 8 hours
____________________________
CHIEF COMPLAINTS
1. Followup of Arrhythmia-Paroxysmal Atrial Fibrillation
2. Followup of CAD, native coronary artery
____________________________
HISTORY OF PRESENT ILLNESS
pt is a very pleasant 78-year-old seasonal visitor from Iowa.
She has paroxysmal atrial fibrillation controlled on Rythmol with Coumadin followed in Iowa, predominant sinus rhythm, peripheral vascular disease with left sided popliteal stent June 2010 with subsequent restenting, type 2 diabetes in 2002, hyperlipidemia, hypertension, bioprosthetic aortic valve replacement in June 2004 with a maze procedure and aortic valve reconstruction and nonobstructive coronary disease as noted then.
No shortness of breath or chest discomfort noted. She had a negative PET nuclear stress test last year.
________________________
PAST HISTORY
Past Medical Illnesses:
DM, hyperlipidemia, hypertension, hypothyroidism, PVD
Past Cardiac Illnesses:
atrial fibrillation, CAD, aortic valve disorder, mitral regurgitation
Surgical Procedures:
AVR tissue June 2004
Cardiology Procedures-Invasive:
multiple cardioversions for afib, cardioversion for afib January 2014
Cardiology Procedures-Noninvasive:
holter monitor 2005, TEE January 2014, Cardiac PET-Lexiscan January 2014
Peripheral Vascular Procedures:
Lt popliteal stent June 2010 and re-stent again
LVEF of 80% documented via Cardiac PET on 01/23/2014
____________________________
___
FAMILY HISTORY
Father -- No relevant family history
CARDIAC RISK FACTORS
Tobacco Abuse: negative; Family History of Heart Disease: negative; Hyperlipidemia: positive; Hypertension: positive; Diabetes Mellitus: positive
____________________________
SOCIAL HISTORY
Alcohol Use - does not use alcohol; Smoking - never smoked;
____________________________
REVIEW OF SYSTEMS
General
denies recent weight loss, weight gain, fever or chills or change in exercise tolerance.
Integumentary
denies any change in hair or nails, rashes, or skin lesions.
Eyes
denies diplopia, history of glaucoma or visual field defects.
Ears, Nose, Throat, Mouth
denies any hearing loss, epistaxis, hoarseness or difficulty speaking.
Respiratory
denies dyspnea, cough, wheezing or hemoptysis.
Cardiovascular
denies chest pain, palpitations, or shortness of breath.
Abdominal
denies ulcer disease, hematochezia or melena.
Musculoskeletal
denies any history of venous insufficiency, arthritic symptoms or back problems.
Neurological
denies any history of recurrent strokes, TIA, or seizure disorder.
Psychiatric
denies any history of depression, substance abuse or change in cognitive functions.
Endocrine
denies any history of heat/cold intolerance, polydipsia, or polyuria
Hematological/Immunologic
denies any food allergies, seasonal allergies, bleeding disorders.
____________________________
PHYSICAL EXAMINATION
VITAL SIGNS:
Blood Pressure:
142/64Sitting, Right arm, regular cuff
Height- 66"
Weight- 132.00 lbs.
Pulse- 80/min. Regular
CONSTITUTIONAL
cooperative, alert and oriented,well developed, well nourished, in no acute distress.
SKIN
warm and dry to touch, no apparent rash.
HEAD
normocephalic, normal hair pattern, no masses or tenderness
EYES
EOMS Intact,pupils equal and round, conjunctivae and lids grossly normal. No icterus.
ENT
ears, nose and throat reveal no gross abnormalities.
NECK
no palpable masses or adenopathy, no thyromegaly, no JVD, carotid pulses are full and equal bilaterally without bruits.
CHEST
normal symmetry, no tenderness to palpation, normal respiratory excursion, no intercostal retraction, no use of accessory muscles, normal diaphragmatic excursion, clear to auscultation.
CARDIAC
soft grade 1/6 systolic ejection murmur
ABDOMEN
abdomen soft, bowel sounds normoactive, no masses, no hepatosplenomegaly, non-tender, no bruits
PERIPHERAL PULSES
the femoral, popliteal, dorsalis pedis, and posterior tibial pulses are full and equal bilaterally with no bruits auscultated.
RECTAL
deferred.
EXTREMITIES & BACK
no deformities, clubbing, cyanosis, erythema or edema observed. Good muscle strength and tone.
LYMPHATICS
no cervical adenopathy.
PSYCHIATRIC
oriented to time, person and place. Affect appropriate.
NEUROLOGICAL
no gross motor or sensory deficits noted, No difficulties with speech or language, oriented to time, person and place.
____________________________
MEDICATIONS UPDATED TODAY:
____________________________
IMPRESSIONS/PLAN
1. Hypothyroidism/medical therapy
2. Diabetes under control
3. Hyperlipidemia
4. Hypertension under control
5. Paroxysmal atrial fibrillation with predominance sinus rhythm. Medicines as above
6. Lower extremity peripheral vascular stenting as above
7. Status post bioprosthetic aortic valve replacement/Maze procedure/ascending thoracic aneurysm repair in 2004.
EKG normal sinus rhythm at 90 beats minute, first-degree AV block, nonspecific ST-T wave abnormalities.
I will see her in one year for review.
____________________________
TODAYS ORDERS:
1. Return Visit 1 year