The EMR assigned 99203 to this visit. I think it is a 99204. All PHI has been removed...
CC:
. Patient presents for pre-op clearance for shoulder surgery Dr R to do surgery when clearance complete
HPI:
Patient is being evaluated for shoulder surgery. His physical activity is limited and ambulates very slowly around the house. The patient is complaining of mild shortness of breath and chest discomfort with physical activity occasionally at rest. He has a distant history of smoking. His baseline EKG showed flattening of the ST-T segment in the precordial leads no obvious ST depression but there is a T-wave inversion in V1 and V2.
ROS:
CONSTITUTIONAL: Negative for chills, fatigue, fever, night sweats and unintentional weight loss.
EYES: Negative for blurred vision and eye pain.
E/N/T: Negative for diminished hearing, hearing aids and nasal congestion.
CARDIOVASCULAR: Positive for chest pain ( unrelated to exertion ) and sob wtih mild activity. Negative for palpitations, paroxysmal nocturnal dyspnea, pedal edema, syncope, presyncope or shortness of breath when laying flat.
RESPIRATORY: Negative for cough, dyspnea and frequent wheezing.
GASTROINTESTINAL: Negative for abdominal pain, acid reflux symptoms, heartburn, nausea, black tarry stool and blood in stool.
GENITOURINARY: Negative for dysuria, hematuria, painful urination and difficulty starting or stopping urine.
MUSCULOSKELETAL: Negative for joint pain, back pain and muscle pain.
INTEGUMENTARY: Negative for change in skin or hair texture.
NEUROLOGICAL: Negative for balance problems, dizziness, fainting, headaches, numbness, slurred speech, tingling, tremor and weakness.
HEMATOLOGIC/LYMPHATIC: Negative for easy bruising and excessive bleeding.
ENDOCRINE: Negative for feeling hot all the time and feeling cold all the time.
PMH/FMH/SH:
Last Reviewed on 4/14/2015 10:27 AM by
Past Medical History:
Hypertension
Benign Prostatic Hypertrophy
CURRENT MEDICAL PROVIDERS:
Primary care provider
Dr
Surgical History:
neck surgery;
left foot surgery secondary to trauma;
Family History:
Father: Healthy
Mother: Healthy
Social History:
Occupation:
Retired
Marital Status: Widowed
Children: 4 children
Exercise: Primary form of exercise is stretch and push ups.
Tobacco/Alcohol/Supplements:
Last Reviewed on 4/14/2015 10:27 AM by
Tobacco: He has a past history of cigarette smoking; quit date: 2000. Non-drinker
Caffeine: He admits to consuming caffeine via coffee ( 1 serving per day ).
Supplements: Patient admits to use of vitamin B.
Substance Abuse History:
Last Reviewed on 4/14/2015 10:27 AM by
NEGATIVE
Mental Health History:
Last Reviewed on 4/14/2015 10:27 AM by
NEGATIVE
Communicable Diseases (eg STDs):
Last Reviewed on 4/14/2015 10:27 AM by
Reportable health conditions; NEGATIVE
Current Problems:
Last Reviewed on 4/14/2015 10:27 AM by
None Recorded
Immunizations:
None
Allergies:
Last Reviewed on 4/14/2015 10:27 AM by
No Known Drug Allergies.
Current Medications:
Last Reviewed on 4/14/2015 10:27 AM by
Amlodipine 5mg Tablet 1 po q day.
Tamsulosin HCl 0.4mg Capsules qd
OBJECTIVE:
Vitals:
Current: 4/14/2015 10:31:10 AM
Ht: 5 ft, 9 in; Wt: 201 lbs; BMI: 29.7
BP: 160/86 mm Hg (left arm, sitting); P: 66 bpm (finger clip, sitting, regular)
O2 Sat: 95 % (room air)
Exams:
PHYSICAL EXAM:
GENERAL: well developed, well nourished; alert and oriented X3, no apparent distress; well groomed;
EYES: sclerae non icteric and without hemorrhage, non erythematous conjunctiva and cornea are normal; PERRLA;
NECK: supple and symmetrical , JVP is 5 cm range of motion is normal; trachea is midline; thyroid is non-palpable; carotid exam is normal with good upstroke and no bruits;
RESPIRATORY: normal respiratory rate and pattern with no distress; clear in all fields percussion is normal without hyperresonance or dullness;
CARDIOVASCULAR: normal rate; rhythm is regular; normal S1 and S2 with no S3/S4 gallop, rubs or clicks; no systolic murmur; no diastolic murmur; 2+ carotid, radial, femoral, and pedal pulses; no cyanosis; 1+ pedal edema;
GASTROINTESTINAL: nontender; normal bowel sounds; no masses; no abdominal or renal bruits;
SKIN: capillary refill normal no obvious rashes or lesions
MUSCULOSKELETAL: normal gait; muscle strength: 5/5 in all major muscle groups; normal overall tone
NEUROLOGIC: cranial nerves: CN 2 - 12 grossly intact; sensation: grossly intact, symetric and within normal limits;
PSYCHIATRIC: appropriate affect and demeanor; normal psychomotor function; normal speech pattern; normal thought and perception;
ASSESSMENT:
V72.81 Preoperative cardiovascular examination
DDx:
786.51 Chest pain
DDx:
786.05 SOB
DDx:
401.1 HTN
DDx:
ORDERS:
Radiology/Test Orders:
Electrocardiogram, routine with at least 12 leads; with interpretation and report (In-House)
Lexiscan cardiolite stress test (Send-Out)
Other Orders:
Echocardiography, transthoracic, complete (Send-Out)
PLAN:
Preoperative cardiovascular examination Patient is being evaluated for shoulder surgery. His physical activity is limited and ambulates very slowly around the house. The patient is complaining of mild shortness of breath and chest discomfort with physical activity occasionally at rest. He has a distant history of smoking. His baseline EKG showed flattening of the ST-T segment in the precordial leads no obvious ST depression but there is a T-wave inversion in V1 and V2. Because of his presentation and risks before I will clear him for surgery like to schedule him for cardiac testing. We're going to get Lexiscan nuclear stress test to rule out coronary etiology for his chest discomfort and an echocardiogram to evaluate LVF, function and rule out valvular disease. The patient will follow up after tests are completed.
FOLLOW-UP: with cardiologist: Dr. W, Schedule a follow-up appointment in 1 week..
Orders:
Electrocardiogram, routine with at least 12 leads; with interpretation and report (In-House)
Chest pain
DIAGNOSTIC TESTS TO BE SCHEDULED: Lexiscan cardiolite stress test;
Orders:
Lexiscan cardiolite stress test (Send-Out)
SOB
DIAGNOSTIC TESTS TO BE SCHEDULED: Echocardiogram, complete study;
Orders:
Echocardiography, transthoracic, complete (Send-Out)
HTN The patient has history of elevated blood pressure. His systolic blood pressure today was 160 mmHg. He is taking amlodipine 5 mg once daily. According to patient his blood pressure is usually within normal limits. I'm not going to change his medications today but if she continues to have a documented hypertension I'm going to increase amlodipine to 10 mg once a day or add another medication.
Patient Recommendations:
For Preoperative cardiovascular examination:
Schedule a follow-up visit in 1 week.
CHARGE CAPTURE:
Primary Diagnosis:
V72.81 Preoperative cardiovascular examination
Orders:
99203 Office visit - new pt, level 3 (In-House)
93000 Electrocardiogram, routine with at least 12 leads; with interpretation and report (In-House)
786.51 Chest pain
786.05 SOB
401.1 HTN
Thanks for any help!
CC:
. Patient presents for pre-op clearance for shoulder surgery Dr R to do surgery when clearance complete
HPI:
Patient is being evaluated for shoulder surgery. His physical activity is limited and ambulates very slowly around the house. The patient is complaining of mild shortness of breath and chest discomfort with physical activity occasionally at rest. He has a distant history of smoking. His baseline EKG showed flattening of the ST-T segment in the precordial leads no obvious ST depression but there is a T-wave inversion in V1 and V2.
ROS:
CONSTITUTIONAL: Negative for chills, fatigue, fever, night sweats and unintentional weight loss.
EYES: Negative for blurred vision and eye pain.
E/N/T: Negative for diminished hearing, hearing aids and nasal congestion.
CARDIOVASCULAR: Positive for chest pain ( unrelated to exertion ) and sob wtih mild activity. Negative for palpitations, paroxysmal nocturnal dyspnea, pedal edema, syncope, presyncope or shortness of breath when laying flat.
RESPIRATORY: Negative for cough, dyspnea and frequent wheezing.
GASTROINTESTINAL: Negative for abdominal pain, acid reflux symptoms, heartburn, nausea, black tarry stool and blood in stool.
GENITOURINARY: Negative for dysuria, hematuria, painful urination and difficulty starting or stopping urine.
MUSCULOSKELETAL: Negative for joint pain, back pain and muscle pain.
INTEGUMENTARY: Negative for change in skin or hair texture.
NEUROLOGICAL: Negative for balance problems, dizziness, fainting, headaches, numbness, slurred speech, tingling, tremor and weakness.
HEMATOLOGIC/LYMPHATIC: Negative for easy bruising and excessive bleeding.
ENDOCRINE: Negative for feeling hot all the time and feeling cold all the time.
PMH/FMH/SH:
Last Reviewed on 4/14/2015 10:27 AM by
Past Medical History:
Hypertension
Benign Prostatic Hypertrophy
CURRENT MEDICAL PROVIDERS:
Primary care provider
Dr
Surgical History:
neck surgery;
left foot surgery secondary to trauma;
Family History:
Father: Healthy
Mother: Healthy
Social History:
Occupation:
Retired
Marital Status: Widowed
Children: 4 children
Exercise: Primary form of exercise is stretch and push ups.
Tobacco/Alcohol/Supplements:
Last Reviewed on 4/14/2015 10:27 AM by
Tobacco: He has a past history of cigarette smoking; quit date: 2000. Non-drinker
Caffeine: He admits to consuming caffeine via coffee ( 1 serving per day ).
Supplements: Patient admits to use of vitamin B.
Substance Abuse History:
Last Reviewed on 4/14/2015 10:27 AM by
NEGATIVE
Mental Health History:
Last Reviewed on 4/14/2015 10:27 AM by
NEGATIVE
Communicable Diseases (eg STDs):
Last Reviewed on 4/14/2015 10:27 AM by
Reportable health conditions; NEGATIVE
Current Problems:
Last Reviewed on 4/14/2015 10:27 AM by
None Recorded
Immunizations:
None
Allergies:
Last Reviewed on 4/14/2015 10:27 AM by
No Known Drug Allergies.
Current Medications:
Last Reviewed on 4/14/2015 10:27 AM by
Amlodipine 5mg Tablet 1 po q day.
Tamsulosin HCl 0.4mg Capsules qd
OBJECTIVE:
Vitals:
Current: 4/14/2015 10:31:10 AM
Ht: 5 ft, 9 in; Wt: 201 lbs; BMI: 29.7
BP: 160/86 mm Hg (left arm, sitting); P: 66 bpm (finger clip, sitting, regular)
O2 Sat: 95 % (room air)
Exams:
PHYSICAL EXAM:
GENERAL: well developed, well nourished; alert and oriented X3, no apparent distress; well groomed;
EYES: sclerae non icteric and without hemorrhage, non erythematous conjunctiva and cornea are normal; PERRLA;
NECK: supple and symmetrical , JVP is 5 cm range of motion is normal; trachea is midline; thyroid is non-palpable; carotid exam is normal with good upstroke and no bruits;
RESPIRATORY: normal respiratory rate and pattern with no distress; clear in all fields percussion is normal without hyperresonance or dullness;
CARDIOVASCULAR: normal rate; rhythm is regular; normal S1 and S2 with no S3/S4 gallop, rubs or clicks; no systolic murmur; no diastolic murmur; 2+ carotid, radial, femoral, and pedal pulses; no cyanosis; 1+ pedal edema;
GASTROINTESTINAL: nontender; normal bowel sounds; no masses; no abdominal or renal bruits;
SKIN: capillary refill normal no obvious rashes or lesions
MUSCULOSKELETAL: normal gait; muscle strength: 5/5 in all major muscle groups; normal overall tone
NEUROLOGIC: cranial nerves: CN 2 - 12 grossly intact; sensation: grossly intact, symetric and within normal limits;
PSYCHIATRIC: appropriate affect and demeanor; normal psychomotor function; normal speech pattern; normal thought and perception;
ASSESSMENT:
V72.81 Preoperative cardiovascular examination
DDx:
786.51 Chest pain
DDx:
786.05 SOB
DDx:
401.1 HTN
DDx:
ORDERS:
Radiology/Test Orders:
Electrocardiogram, routine with at least 12 leads; with interpretation and report (In-House)
Lexiscan cardiolite stress test (Send-Out)
Other Orders:
Echocardiography, transthoracic, complete (Send-Out)
PLAN:
Preoperative cardiovascular examination Patient is being evaluated for shoulder surgery. His physical activity is limited and ambulates very slowly around the house. The patient is complaining of mild shortness of breath and chest discomfort with physical activity occasionally at rest. He has a distant history of smoking. His baseline EKG showed flattening of the ST-T segment in the precordial leads no obvious ST depression but there is a T-wave inversion in V1 and V2. Because of his presentation and risks before I will clear him for surgery like to schedule him for cardiac testing. We're going to get Lexiscan nuclear stress test to rule out coronary etiology for his chest discomfort and an echocardiogram to evaluate LVF, function and rule out valvular disease. The patient will follow up after tests are completed.
FOLLOW-UP: with cardiologist: Dr. W, Schedule a follow-up appointment in 1 week..
Orders:
Electrocardiogram, routine with at least 12 leads; with interpretation and report (In-House)
Chest pain
DIAGNOSTIC TESTS TO BE SCHEDULED: Lexiscan cardiolite stress test;
Orders:
Lexiscan cardiolite stress test (Send-Out)
SOB
DIAGNOSTIC TESTS TO BE SCHEDULED: Echocardiogram, complete study;
Orders:
Echocardiography, transthoracic, complete (Send-Out)
HTN The patient has history of elevated blood pressure. His systolic blood pressure today was 160 mmHg. He is taking amlodipine 5 mg once daily. According to patient his blood pressure is usually within normal limits. I'm not going to change his medications today but if she continues to have a documented hypertension I'm going to increase amlodipine to 10 mg once a day or add another medication.
Patient Recommendations:
For Preoperative cardiovascular examination:
Schedule a follow-up visit in 1 week.
CHARGE CAPTURE:
Primary Diagnosis:
V72.81 Preoperative cardiovascular examination
Orders:
99203 Office visit - new pt, level 3 (In-House)
93000 Electrocardiogram, routine with at least 12 leads; with interpretation and report (In-House)
786.51 Chest pain
786.05 SOB
401.1 HTN
Thanks for any help!