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Dx I chose: K52.9; R11.2; Z90.49
CPT I chose: 99214-25; 93010; 93042-59
EMERGENCY DEPARTMENT
SEX: MALE AGE: 69
DOS: 1/1/20XX
Time Seen: 10:23 Arrived- By ambulance. fentanyl and Zofran. IV and pulse oximeter in place. Historian- patient and EMS personnel. History limited by vague historian.
HISTORY OF PRESENT ILLNESS:
Chief complaint- ABDOMINAL PAIN and FLANK PAIN. This started last night about 0300 and is still present (persistent). It was abrupt in onset and has been constant. It is described as pain and it is described as located in the right abdomen and in the periumbilical area. No radiation. At its maximum, severity described as severe. When seen in the E.D., severity described as severe. Modifying factors- worsened by food. Not relieved by anything. He has had nausea, loss of appetite and vomiting. No diarrhea. Similar symptoms previously: None.
Recent medical care: The patient was seen recently at this facility (2 days ago, CXR NAD).
REVIEW OF SYSTEMS: No hematemesis, difficulty with urination, fever, chest pain or difficulty breathing. No cough, chills or back pain. All systems otherwise negative, except as recorded above.
PAST HISTORY: See nurses’ notes. Has not had urinary calculi.
Surgeries: Prior abdominal surgery: gall bladder surgery.
Medications: Unknown.
SOCIAL HISTORY: Nonsmoker.
ADDITIONAL NOTES: The nursing notes have been reviewed with agreement regarding the chief complaint, HPI, ROS, PMH and patient medications and allergies. Fausto Thomas, MD
Electronically signed by FAUSTO THOMAS, MD 1/1/20XX
PHYSICAL EXAM:
Appearance: Alert. Oriented X3. Oxygen being administered by nasal cannula. IV present X 1. EKG monitor and O2 sat monitor on the patient. Anxious. Appears to be in pain. Patient in moderate distress. (nontoxic, seems mildly retarded).
Vital Signs: Normal and appear to be correct. (BP: 136/88. HR: 94. RR: 20. Temp: 99. O2 saturation: 99 on nasal cannula at 4 liter/minute.).
Eyes: Pupils equal, round and reactive to light. Eyes normal inspection. No scleral icterus or pale conjunctivae.
ENT: Nose normal. Mildly dry mucous membranes present.
Neck: Normal inspection. Neck supple.
CVS: Normal heart rate and rhythm. Heart sounds normal.
Respiratory: No respiratory distress. Breath sounds normal.
Abdomen: Soft. Tenderness in the periumbilical area. Bowel sounds normal. No organomegaly. No mass. Femoral pulses equal. Moderately obese. No pulsatile mass present, rebound tenderness or guarding.
Back: No CVA tenderness.
Skin: Skin warm and dry. Normal skin color. No rash.
Extremities: No lower extremity edema.
Neuro: Oriented X 3. No motor deficit.
LABS, X-RAYS, AND EKG:
EKG: 12 lead EKG time (1126). Normal sinus rhythm. Rate: 66. Normal P waves. Normal QRS complex. Normal axis. Normal ST and T waves and QT. Prior EKG unavailable. The study has been independently viewed and interpreted by me. The EKG appears to be a good tracing.
Rhythm Strip #1: Time (1130). Rate= 65. Normal sinus rhythm. Regular rhythm. Narrow QRS complexes. No ectopy. Conduction normal. Normal ST segments and T waves. The study was interpreted by me.
Fausto Thomas, MD
Electronically signed by FAUSTO THOMAS, MD 1/1/20XX
Chest X-ray: Normal Chest X-Ray (AP and portable): independently viewed and interpreted by Radiologist. Normal heart size. Normal mediastinum. Normal soft tissues. No infiltrates present. No pneumothorax present.
KUB: (?SBO, multi loops dilated sm bowel, no free air). Views: two-view AP.
Abdominal CT: HISTORY: Acute abdominal pain. Questionable small bowel obstruction on x-ray.
FINDINGS: Comparison is April 11, 20XX.
Cholecystectomy clips are identified. There is some fatty infiltration of the liver. The spleen, pancreas, adrenal glands, and kidneys are normal. The abdominal aorta is normal in caliber. There is no evidence pathologic adenopathy, mesenteric inflammatory change or free intra-abdominal fluid/gas. Is a normal bowel gas pattern. I do not see any evidence of a small bowel obstruction. I do not identify the appendix as a distinct entity. There is no evidence of acute appendicitis. Images into the pelvis show no free intrapelvic fluid. Bladder is grossly unremarkable. No evidence of inguinal hernia.
IMPRESSION: Mild fatty infiltration of the liver otherwise normal abdomen and pelvic CT.
Paul Kramer, MD
Electronically signed by PAUL KRAMER, MD 1/1/20XX
Laboratory Tests: Laboratory tests have been ordered, with results reviewed and considered in the medical decision-making process.
0425:YJ:S00002S: (COLL: 01/1/20XX 10:15) ( MsgRcvd 0/1/20XX 11:36) Final results
Laboratory Test Value
RAPID H PYLORI NEGATIVE
0425:YJ:C00224S: (COLL: 01/1/20XX 10:15) ( MsgRcvd 01/3/20XX 11:40) Final results
Laboratory Test Value
LIPASE LIQUID REAGENTS 140
SODIUM 138
POTASSIUM 4.0
CHLORIDE 99
CARBON DIOXIDE 24.0
ANION GAP 15
GLUCOSE 148
BLOOD UREA NITROGEN 15
CREATININE 1.10
GLOMERULAR FILTRATION RATE > 60
TOTAL PROTEIN 8.1
ALBUMIN 4.1
CALCIUM 10.3
BILIRUBIN TOTAL 0.50
SGOT/AST 15
SGPT/ALT 48
ALKALINE PHOSPHATASE 86
CREATINE KINASE (CK) 140
TROPONIN I < 0.02
0425:YJ:U00032S: (COLL: 01/1/20XX 14:50) ( MsgRcvd 01/1/20XX 15:23)
Laboratory Test Value
UA COLOR YELLOW
UA APPEARANCE CLEAR
UA GLUCOSE DIPSTICK NORM
UA BILIRUBIN DIPSTICK NEG
UA KETONE DIPSTICK 5
UA SPECIFIC GRAVITY 1.050
UA BLOOD DIPSTICK NEG
UA PH DIPSTICK 7.0
UA PROTEIN DIPSTICK 25
UA UROBILINOGEN DIPSTICK NORM
UA NITRITE DIPSTICK NEG
UA LEUKOCYTE ESTERASE DIPSTICK NEG
UA RBC
UA WBC
ADDIT URINALYSIS TESTS?
URINE CULTURE NEEDED?
0425:YJ:CG00087S: (COLL: 01/1/20XX 10:15) ( MsgRcvd 01/1/20XX 11:58) Final results
Laboratory Test Value
PT PATIENT 10.1
INTERNATIONAL NORMAL RATIO 0.90
0425:YJ:H00156S: (COLL: 01/1/20XX 10:15) ( MsgRcvd 01/1/20XX 11:25) Final results
Laboratory Test Value
WHITE BLOOD CELL 9.6
RED BLOOD CELL 5.28
HEMOGLOBIN 15.4
HEMATOCRIT 46.0
MEAN CELL VOLUME 87.1
MEAN CELL HGB 29.2
MEAN CELL HGB CONCENTRATION 33.5
RED CELL DISTRIBUTION WIDTH 14.6
PLATELET COUNT 224
MEAN PLATELET VOLUME 10.0
NEUTROPHIL % 74.9
LYMPHOCYTE % 19.8
MONOCYTE % 4.9
EOSINOPHIL % 0.2
BASOPHIL % 0.2
NEUTROPHIL # 7.2
LYMPHOCYTE # 1.9
MONOCYTE # 0.5
EOSINOPHIL # 0.0
BASOPHIL # 0.0
MANUAL DIFF REQUIRED? NO
SMEAR REVIEW ? NO
NP AUTO DIFF NO
PROGRESS AND PROCEDURES
Course of Care: patient presents by EMS retching loudly, basically dry heaving, tells me he had sudden onset of severe mid abdominal pain that awakened him at 3 a.m. he has had multiple episodes of vomiting and diarrhea. His gallbladder is surgically absent. He denies any known history of pancreatitis or ulcers, has had no hematemesis or blood per rectum. Patient is tender in the midabdomen. IV fluids are given along with IV Zofran and hydromorphone and IV Protonix while awaiting results of tests. Acute abdominal series with chest x-ray is also ordered to make sure this does represent a perforated ulcer or other viscus by the presence of free air. Film shows some mildly dilated loops of small bowel but no free air. Patient's CBC is normal and on re-exam he seems quite a bit more comfortable. CT of abdomen and pelvis with dual contrast is ordered, although due to retching the patient is only able to keep down about 200 mL of the oral contrast, suggesting a bowel obstruction or ileus clinically. I review with the patient that his CT scan shows no acute disease such as appendicitis, aneurysm, pancreatitis, perforated viscus or bowel obstruction. His lipase is normal and H. pylori is negative. the vomiting and diarrhea and the suggestion of ileus on his radiographic studies would suggest the probability of viral gastroenteritis, although he thinks it is food poisoning from eating at the Cottonwood Creek assisted living facility. he says the nursing director there does not like him and he does not like the food and generally complains about the facility. On re-examination he does not appear acutely ill and is worried that he needs something to eat and would also like a Lortab. I recommend clear liquids for the next 12 hours with advancing diet as tolerated and to have a discussion with their dietary staff regarding his food choices. He is given a Zofran ODT and Lortab p.o. in the ED with prescriptions for same. I emphasized to him the importance of following up with his PMD if his symptoms don't resolve promptly. He verbalizes his understanding of this discussion. Transporter arrives to take him back to CrCC, he is brought right back by WC puking bilious liquid. I order NG tube and d/w Dr Andrews to admit Obs for intractable vomiting.
Patient counseled in person regarding the patient's stable condition, test results, diagnosis
Medication administered under direct supervision of physician; IV fluid administered under direct supervision of physician.
Clinical Review Considered abdominal aortic aneurysm.
CLINICAL IMPRESSION:
Intractable vomiting.
Acute gastroenteritis.
INSTRUCTIONS:
Prescription Medications:
Lortab 7.5 mg: take 1 orally every 4 hours as needed for pain. Dispense ten (10). No refill. Generic substitute OK.
Zofran (orally disintegrating tablets) 4 mg: take 1 orally every 6 hours as needed for nausea. Dispense ten (10). No refill. Generic substitute OK.
Fausto Thomas, MD
Electronically signed by FAUSTO THOMAS, MD 1/1/20XX
Any laboratory data incorporated in this document has been entered by the emergency clinician and may have been summarized or otherwise modified. The original full report is available in Meditech. Please refer to PCI for the Performing site information.
Did I do this practicode correctly?
Thank you
Dx I chose: K52.9; R11.2; Z90.49
CPT I chose: 99214-25; 93010; 93042-59
EMERGENCY DEPARTMENT
SEX: MALE AGE: 69
DOS: 1/1/20XX
Time Seen: 10:23 Arrived- By ambulance. fentanyl and Zofran. IV and pulse oximeter in place. Historian- patient and EMS personnel. History limited by vague historian.
HISTORY OF PRESENT ILLNESS:
Chief complaint- ABDOMINAL PAIN and FLANK PAIN. This started last night about 0300 and is still present (persistent). It was abrupt in onset and has been constant. It is described as pain and it is described as located in the right abdomen and in the periumbilical area. No radiation. At its maximum, severity described as severe. When seen in the E.D., severity described as severe. Modifying factors- worsened by food. Not relieved by anything. He has had nausea, loss of appetite and vomiting. No diarrhea. Similar symptoms previously: None.
Recent medical care: The patient was seen recently at this facility (2 days ago, CXR NAD).
REVIEW OF SYSTEMS: No hematemesis, difficulty with urination, fever, chest pain or difficulty breathing. No cough, chills or back pain. All systems otherwise negative, except as recorded above.
PAST HISTORY: See nurses’ notes. Has not had urinary calculi.
Surgeries: Prior abdominal surgery: gall bladder surgery.
Medications: Unknown.
SOCIAL HISTORY: Nonsmoker.
ADDITIONAL NOTES: The nursing notes have been reviewed with agreement regarding the chief complaint, HPI, ROS, PMH and patient medications and allergies. Fausto Thomas, MD
Electronically signed by FAUSTO THOMAS, MD 1/1/20XX
PHYSICAL EXAM:
Appearance: Alert. Oriented X3. Oxygen being administered by nasal cannula. IV present X 1. EKG monitor and O2 sat monitor on the patient. Anxious. Appears to be in pain. Patient in moderate distress. (nontoxic, seems mildly retarded).
Vital Signs: Normal and appear to be correct. (BP: 136/88. HR: 94. RR: 20. Temp: 99. O2 saturation: 99 on nasal cannula at 4 liter/minute.).
Eyes: Pupils equal, round and reactive to light. Eyes normal inspection. No scleral icterus or pale conjunctivae.
ENT: Nose normal. Mildly dry mucous membranes present.
Neck: Normal inspection. Neck supple.
CVS: Normal heart rate and rhythm. Heart sounds normal.
Respiratory: No respiratory distress. Breath sounds normal.
Abdomen: Soft. Tenderness in the periumbilical area. Bowel sounds normal. No organomegaly. No mass. Femoral pulses equal. Moderately obese. No pulsatile mass present, rebound tenderness or guarding.
Back: No CVA tenderness.
Skin: Skin warm and dry. Normal skin color. No rash.
Extremities: No lower extremity edema.
Neuro: Oriented X 3. No motor deficit.
LABS, X-RAYS, AND EKG:
EKG: 12 lead EKG time (1126). Normal sinus rhythm. Rate: 66. Normal P waves. Normal QRS complex. Normal axis. Normal ST and T waves and QT. Prior EKG unavailable. The study has been independently viewed and interpreted by me. The EKG appears to be a good tracing.
Rhythm Strip #1: Time (1130). Rate= 65. Normal sinus rhythm. Regular rhythm. Narrow QRS complexes. No ectopy. Conduction normal. Normal ST segments and T waves. The study was interpreted by me.
Fausto Thomas, MD
Electronically signed by FAUSTO THOMAS, MD 1/1/20XX
Chest X-ray: Normal Chest X-Ray (AP and portable): independently viewed and interpreted by Radiologist. Normal heart size. Normal mediastinum. Normal soft tissues. No infiltrates present. No pneumothorax present.
KUB: (?SBO, multi loops dilated sm bowel, no free air). Views: two-view AP.
Abdominal CT: HISTORY: Acute abdominal pain. Questionable small bowel obstruction on x-ray.
FINDINGS: Comparison is April 11, 20XX.
Cholecystectomy clips are identified. There is some fatty infiltration of the liver. The spleen, pancreas, adrenal glands, and kidneys are normal. The abdominal aorta is normal in caliber. There is no evidence pathologic adenopathy, mesenteric inflammatory change or free intra-abdominal fluid/gas. Is a normal bowel gas pattern. I do not see any evidence of a small bowel obstruction. I do not identify the appendix as a distinct entity. There is no evidence of acute appendicitis. Images into the pelvis show no free intrapelvic fluid. Bladder is grossly unremarkable. No evidence of inguinal hernia.
IMPRESSION: Mild fatty infiltration of the liver otherwise normal abdomen and pelvic CT.
Paul Kramer, MD
Electronically signed by PAUL KRAMER, MD 1/1/20XX
Laboratory Tests: Laboratory tests have been ordered, with results reviewed and considered in the medical decision-making process.
0425:YJ:S00002S: (COLL: 01/1/20XX 10:15) ( MsgRcvd 0/1/20XX 11:36) Final results
Laboratory Test Value
RAPID H PYLORI NEGATIVE
0425:YJ:C00224S: (COLL: 01/1/20XX 10:15) ( MsgRcvd 01/3/20XX 11:40) Final results
Laboratory Test Value
LIPASE LIQUID REAGENTS 140
SODIUM 138
POTASSIUM 4.0
CHLORIDE 99
CARBON DIOXIDE 24.0
ANION GAP 15
GLUCOSE 148
BLOOD UREA NITROGEN 15
CREATININE 1.10
GLOMERULAR FILTRATION RATE > 60
TOTAL PROTEIN 8.1
ALBUMIN 4.1
CALCIUM 10.3
BILIRUBIN TOTAL 0.50
SGOT/AST 15
SGPT/ALT 48
ALKALINE PHOSPHATASE 86
CREATINE KINASE (CK) 140
TROPONIN I < 0.02
0425:YJ:U00032S: (COLL: 01/1/20XX 14:50) ( MsgRcvd 01/1/20XX 15:23)
Laboratory Test Value
UA COLOR YELLOW
UA APPEARANCE CLEAR
UA GLUCOSE DIPSTICK NORM
UA BILIRUBIN DIPSTICK NEG
UA KETONE DIPSTICK 5
UA SPECIFIC GRAVITY 1.050
UA BLOOD DIPSTICK NEG
UA PH DIPSTICK 7.0
UA PROTEIN DIPSTICK 25
UA UROBILINOGEN DIPSTICK NORM
UA NITRITE DIPSTICK NEG
UA LEUKOCYTE ESTERASE DIPSTICK NEG
UA RBC
UA WBC
ADDIT URINALYSIS TESTS?
URINE CULTURE NEEDED?
0425:YJ:CG00087S: (COLL: 01/1/20XX 10:15) ( MsgRcvd 01/1/20XX 11:58) Final results
Laboratory Test Value
PT PATIENT 10.1
INTERNATIONAL NORMAL RATIO 0.90
0425:YJ:H00156S: (COLL: 01/1/20XX 10:15) ( MsgRcvd 01/1/20XX 11:25) Final results
Laboratory Test Value
WHITE BLOOD CELL 9.6
RED BLOOD CELL 5.28
HEMOGLOBIN 15.4
HEMATOCRIT 46.0
MEAN CELL VOLUME 87.1
MEAN CELL HGB 29.2
MEAN CELL HGB CONCENTRATION 33.5
RED CELL DISTRIBUTION WIDTH 14.6
PLATELET COUNT 224
MEAN PLATELET VOLUME 10.0
NEUTROPHIL % 74.9
LYMPHOCYTE % 19.8
MONOCYTE % 4.9
EOSINOPHIL % 0.2
BASOPHIL % 0.2
NEUTROPHIL # 7.2
LYMPHOCYTE # 1.9
MONOCYTE # 0.5
EOSINOPHIL # 0.0
BASOPHIL # 0.0
MANUAL DIFF REQUIRED? NO
SMEAR REVIEW ? NO
NP AUTO DIFF NO
PROGRESS AND PROCEDURES
Course of Care: patient presents by EMS retching loudly, basically dry heaving, tells me he had sudden onset of severe mid abdominal pain that awakened him at 3 a.m. he has had multiple episodes of vomiting and diarrhea. His gallbladder is surgically absent. He denies any known history of pancreatitis or ulcers, has had no hematemesis or blood per rectum. Patient is tender in the midabdomen. IV fluids are given along with IV Zofran and hydromorphone and IV Protonix while awaiting results of tests. Acute abdominal series with chest x-ray is also ordered to make sure this does represent a perforated ulcer or other viscus by the presence of free air. Film shows some mildly dilated loops of small bowel but no free air. Patient's CBC is normal and on re-exam he seems quite a bit more comfortable. CT of abdomen and pelvis with dual contrast is ordered, although due to retching the patient is only able to keep down about 200 mL of the oral contrast, suggesting a bowel obstruction or ileus clinically. I review with the patient that his CT scan shows no acute disease such as appendicitis, aneurysm, pancreatitis, perforated viscus or bowel obstruction. His lipase is normal and H. pylori is negative. the vomiting and diarrhea and the suggestion of ileus on his radiographic studies would suggest the probability of viral gastroenteritis, although he thinks it is food poisoning from eating at the Cottonwood Creek assisted living facility. he says the nursing director there does not like him and he does not like the food and generally complains about the facility. On re-examination he does not appear acutely ill and is worried that he needs something to eat and would also like a Lortab. I recommend clear liquids for the next 12 hours with advancing diet as tolerated and to have a discussion with their dietary staff regarding his food choices. He is given a Zofran ODT and Lortab p.o. in the ED with prescriptions for same. I emphasized to him the importance of following up with his PMD if his symptoms don't resolve promptly. He verbalizes his understanding of this discussion. Transporter arrives to take him back to CrCC, he is brought right back by WC puking bilious liquid. I order NG tube and d/w Dr Andrews to admit Obs for intractable vomiting.
Patient counseled in person regarding the patient's stable condition, test results, diagnosis
Medication administered under direct supervision of physician; IV fluid administered under direct supervision of physician.
Clinical Review Considered abdominal aortic aneurysm.
CLINICAL IMPRESSION:
Intractable vomiting.
Acute gastroenteritis.
INSTRUCTIONS:
Prescription Medications:
Lortab 7.5 mg: take 1 orally every 4 hours as needed for pain. Dispense ten (10). No refill. Generic substitute OK.
Zofran (orally disintegrating tablets) 4 mg: take 1 orally every 6 hours as needed for nausea. Dispense ten (10). No refill. Generic substitute OK.
Fausto Thomas, MD
Electronically signed by FAUSTO THOMAS, MD 1/1/20XX
Any laboratory data incorporated in this document has been entered by the emergency clinician and may have been summarized or otherwise modified. The original full report is available in Meditech. Please refer to PCI for the Performing site information.
