jmcalhaney
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I was wondering if I could get opinions on what level of service should be billed in this case.
HPI: 70 yo male with a past history significant for HTN, obesity, and OSA on CPAP. He was diagnosed with PE in Aug '11. He also had an abnormal scan with small lung nodules and nonpathologic lymphadenopathy. The patient was admitted to the hospital in Nov 2012 with CHF, cardiomyopathy, and pleural effusion. Pulmonary was consulted and the pt was evaluated by Dr. ******. He did not think it was malignant, but his lymph nodes were related to CHF. The patient is here today for a follow up. He says he has been doing great. No breathing problems at all. No SOB. No Fever of Chills. No weight loss. Actually he gained 7 pounds since last seen.
ROS: As per the HPI; otherwise negative
Current Meds: Reviewed
Allergies: NKDA
Exam
Appearance: Patient is awake, alert, and oriented in no apparent distress
Vitals: BP is 220/110; HR is 70; RR is 16; Temp is 98.2; Weight is 280
HEENT: Head atraumatic, normocephalic. Anicteric sclerae. EOMI. Oropharynx score is 4.
Neck: supple
Lungs: clear to auscultation bilaterally
Heart: S1, S2, RRR
Abdomen: Soft, nontender. Bowel Sounds are positive
Lower Extremities: Trace Edema
Skin: Warm and Dry
Neurologic: No focal deficit
DATA REVIEW: A CT scan of the chest was done on 1/9/13 with IV contrast showing small noncalcified pulmonary nodules, all apprearing stable. Recommend progress study in 6 months.
Impression:
1. Pulmonary nodules, which are all stable and less than 6 mm in diameter.
2. Malignant HTN. The patient has very high BP. I advised him to go to the ER so they can control it given all his comorbidities. Patient refused. He prefers to see Dr. *****. We contacted Dr. ***** and he will be seen now. Our respiratory technician walked him to Dr. ******'s office.
3. Obstructive Sleep Apnea. He is very compliant with his CPAP
4. Obesity. Weight loss was discussed with the patient
5. The patient will follow up in the pulmonary office in 6 months to review CT scan.
HPI: 70 yo male with a past history significant for HTN, obesity, and OSA on CPAP. He was diagnosed with PE in Aug '11. He also had an abnormal scan with small lung nodules and nonpathologic lymphadenopathy. The patient was admitted to the hospital in Nov 2012 with CHF, cardiomyopathy, and pleural effusion. Pulmonary was consulted and the pt was evaluated by Dr. ******. He did not think it was malignant, but his lymph nodes were related to CHF. The patient is here today for a follow up. He says he has been doing great. No breathing problems at all. No SOB. No Fever of Chills. No weight loss. Actually he gained 7 pounds since last seen.
ROS: As per the HPI; otherwise negative
Current Meds: Reviewed
Allergies: NKDA
Exam
Appearance: Patient is awake, alert, and oriented in no apparent distress
Vitals: BP is 220/110; HR is 70; RR is 16; Temp is 98.2; Weight is 280
HEENT: Head atraumatic, normocephalic. Anicteric sclerae. EOMI. Oropharynx score is 4.
Neck: supple
Lungs: clear to auscultation bilaterally
Heart: S1, S2, RRR
Abdomen: Soft, nontender. Bowel Sounds are positive
Lower Extremities: Trace Edema
Skin: Warm and Dry
Neurologic: No focal deficit
DATA REVIEW: A CT scan of the chest was done on 1/9/13 with IV contrast showing small noncalcified pulmonary nodules, all apprearing stable. Recommend progress study in 6 months.
Impression:
1. Pulmonary nodules, which are all stable and less than 6 mm in diameter.
2. Malignant HTN. The patient has very high BP. I advised him to go to the ER so they can control it given all his comorbidities. Patient refused. He prefers to see Dr. *****. We contacted Dr. ***** and he will be seen now. Our respiratory technician walked him to Dr. ******'s office.
3. Obstructive Sleep Apnea. He is very compliant with his CPAP
4. Obesity. Weight loss was discussed with the patient
5. The patient will follow up in the pulmonary office in 6 months to review CT scan.