MLoadman
New
I coded for the onset angina with atherosclerotic heart disease as the primary diagnosis. I also coded for the narcolpesy, history of substance abuse, ocd, lower extremity edema, and restless leg syndrome. According to the answer key, I was only supposed to code for the onset angina with atherosclerotic heart disease.
MEDICAL RECORD
OFFICE - NEW
Robert Jones, MD
CARDIOLOGY
SEX: Female
AGE: 73
Date: 01/01/20XX
PROBLEM LIST:
1. Patient is a retired registered nurse with history of brief rapid palpitations.
2. History of narcolepsy occurring 2-3 x/wk.
3. One episode of confusion. Told it was “temporary global amnesia,” July 20XX. No further episodes.
4. History of substance abuse with Benzodiazepine — none x several years.
5. History of obsessive compulsive disorder.
6. Lower extremity edema.
7. Restless leg syndrome.
ALLERGIES: Multiple statins aggravate her restless leg syndrome.
MEDICATIONS:
Klonopin 1.5 mg q.h.s. Neurontin 400-800 mg t.i.d. to max 3200 mg a day
Compounded estrogen q.d.
Vytorin 10/40 mg 1/2 to 1 tab q.a.m. Aspirin 81 mg q.d.
Lasix 20 mg p.r.n.
Calcium 1200 mg 3 x weekly
Multivitamins q.d.
B5 q.h.s. Amitiza 24 mcg b.i.d.
Folic acid t.i.d.
Comp9ound hormones
Melatonin 10 mg q.h.s. Niacin 250 mg b.i.d.
DHEA 12.5 mg q.a.m. Zofran 4 mg p.r.n. nausea
INTERVAL HISTORY: The patient had a CT scan of the chest to evaluate for pulmonary nodules.
CT chest (4 days ago in ER) shows:
1. This found extensive left coronary calcification, (atherosclerotic) which led to a stress echo today.
She notes that she has chest pain approximately a week to 10 days ago while watching the Olympics. She describes an anterior discomfort with no radiation and some difficulty breathing. This resolved spontaneously in 20 minutes. She has rarely had this in the past.
Labs (4 days ago in ER) show:
1. Lipids: Total cholesterol 210, triglycerides 97, HDL 85, LDL 106.
Notably she presented to the emergency room four days ago with TIA-like symptoms. She describes sensory loss on the left side of her tongue, the left half of her face and the left upper extremity. This spontaneously resolved. Workup in the emergency department was negative. This included a CT scan of the head. She has had carotid Dopplers performed several years ago.
PHYSICAL EXAMINATION
VITAL SIGNS: BP 118/70, pulse is 71 and regular. Oxygen saturation is 93% on room air.
CONSTITUTIONAL: In no acute distress.
HEENT: Eyes: No xanthelasma or exophthalmos. No arcus senilis. Tongue midline. Mucous membranes moist, with no cyanosis.
RESPIRATORY: Respirations even and unlabored. Good air entry bilaterally. No
adventitious sounds. Chest has normal contour.
CARDIOVASCULAR: PMI normal. Neck veins flat. No carotid or subclavian bruits. S1, S2 and normal. No murmur, clicks or gallops. Abdominal aorta not palpable, no bruit. Femoral, tibial, dorsalis pedis pulses intact. No leg swelling.
GASTROINTESTINAL: Abdomen: Soft. Positive BS x4 quads. No tenderness or vascular masses. No hepatosplenomegaly.
SKIN: Pink, warm and dry. Skin intact. No rashes. No lesions. No clubbing or cyanosis.
NEUROLOGIC/PSYCH: Cranial nerves II-XII grossly intact. Alert and oriented x3. Affect normal.
ASSESSMENT:
1. New onset angina.
2. Suspected TIA.
3. Atherosclerotic heart disease
PLAN:
1. Proceed to left heart catheterization including coronary angiogram.
2. Up-titrate niacin as tolerated to 500 mg b.i.d. 3. She needs a carotid Doppler to evaluate for possible TIA symptoms.
Robert Jones, MD
Electronically signed by ROBERT JONES, MD 1/1/20XX
MEDICAL RECORD
OFFICE - NEW
Robert Jones, MD
CARDIOLOGY
SEX: Female
AGE: 73
Date: 01/01/20XX
PROBLEM LIST:
1. Patient is a retired registered nurse with history of brief rapid palpitations.
2. History of narcolepsy occurring 2-3 x/wk.
3. One episode of confusion. Told it was “temporary global amnesia,” July 20XX. No further episodes.
4. History of substance abuse with Benzodiazepine — none x several years.
5. History of obsessive compulsive disorder.
6. Lower extremity edema.
7. Restless leg syndrome.
ALLERGIES: Multiple statins aggravate her restless leg syndrome.
MEDICATIONS:
Klonopin 1.5 mg q.h.s. Neurontin 400-800 mg t.i.d. to max 3200 mg a day
Compounded estrogen q.d.
Vytorin 10/40 mg 1/2 to 1 tab q.a.m. Aspirin 81 mg q.d.
Lasix 20 mg p.r.n.
Calcium 1200 mg 3 x weekly
Multivitamins q.d.
B5 q.h.s. Amitiza 24 mcg b.i.d.
Folic acid t.i.d.
Comp9ound hormones
Melatonin 10 mg q.h.s. Niacin 250 mg b.i.d.
DHEA 12.5 mg q.a.m. Zofran 4 mg p.r.n. nausea
INTERVAL HISTORY: The patient had a CT scan of the chest to evaluate for pulmonary nodules.
CT chest (4 days ago in ER) shows:
1. This found extensive left coronary calcification, (atherosclerotic) which led to a stress echo today.
She notes that she has chest pain approximately a week to 10 days ago while watching the Olympics. She describes an anterior discomfort with no radiation and some difficulty breathing. This resolved spontaneously in 20 minutes. She has rarely had this in the past.
Labs (4 days ago in ER) show:
1. Lipids: Total cholesterol 210, triglycerides 97, HDL 85, LDL 106.
Notably she presented to the emergency room four days ago with TIA-like symptoms. She describes sensory loss on the left side of her tongue, the left half of her face and the left upper extremity. This spontaneously resolved. Workup in the emergency department was negative. This included a CT scan of the head. She has had carotid Dopplers performed several years ago.
PHYSICAL EXAMINATION
VITAL SIGNS: BP 118/70, pulse is 71 and regular. Oxygen saturation is 93% on room air.
CONSTITUTIONAL: In no acute distress.
HEENT: Eyes: No xanthelasma or exophthalmos. No arcus senilis. Tongue midline. Mucous membranes moist, with no cyanosis.
RESPIRATORY: Respirations even and unlabored. Good air entry bilaterally. No
adventitious sounds. Chest has normal contour.
CARDIOVASCULAR: PMI normal. Neck veins flat. No carotid or subclavian bruits. S1, S2 and normal. No murmur, clicks or gallops. Abdominal aorta not palpable, no bruit. Femoral, tibial, dorsalis pedis pulses intact. No leg swelling.
GASTROINTESTINAL: Abdomen: Soft. Positive BS x4 quads. No tenderness or vascular masses. No hepatosplenomegaly.
SKIN: Pink, warm and dry. Skin intact. No rashes. No lesions. No clubbing or cyanosis.
NEUROLOGIC/PSYCH: Cranial nerves II-XII grossly intact. Alert and oriented x3. Affect normal.
ASSESSMENT:
1. New onset angina.
2. Suspected TIA.
3. Atherosclerotic heart disease
PLAN:
1. Proceed to left heart catheterization including coronary angiogram.
2. Up-titrate niacin as tolerated to 500 mg b.i.d. 3. She needs a carotid Doppler to evaluate for possible TIA symptoms.
Robert Jones, MD
Electronically signed by ROBERT JONES, MD 1/1/20XX
MEDICAL RECORD
OFFICE - NEW
Robert Jones, MD
CARDIOLOGY
SEX: Female
AGE: 73
Date: 01/01/20XX
PROBLEM LIST:
1. Patient is a retired registered nurse with history of brief rapid palpitations.
2. History of narcolepsy occurring 2-3 x/wk.
3. One episode of confusion. Told it was “temporary global amnesia,” July 20XX. No further episodes.
4. History of substance abuse with Benzodiazepine — none x several years.
5. History of obsessive compulsive disorder.
6. Lower extremity edema.
7. Restless leg syndrome.
ALLERGIES: Multiple statins aggravate her restless leg syndrome.
MEDICATIONS:
Klonopin 1.5 mg q.h.s. Neurontin 400-800 mg t.i.d. to max 3200 mg a day
Compounded estrogen q.d.
Vytorin 10/40 mg 1/2 to 1 tab q.a.m. Aspirin 81 mg q.d.
Lasix 20 mg p.r.n.
Calcium 1200 mg 3 x weekly
Multivitamins q.d.
B5 q.h.s. Amitiza 24 mcg b.i.d.
Folic acid t.i.d.
Comp9ound hormones
Melatonin 10 mg q.h.s. Niacin 250 mg b.i.d.
DHEA 12.5 mg q.a.m. Zofran 4 mg p.r.n. nausea
INTERVAL HISTORY: The patient had a CT scan of the chest to evaluate for pulmonary nodules.
CT chest (4 days ago in ER) shows:
1. This found extensive left coronary calcification, (atherosclerotic) which led to a stress echo today.
She notes that she has chest pain approximately a week to 10 days ago while watching the Olympics. She describes an anterior discomfort with no radiation and some difficulty breathing. This resolved spontaneously in 20 minutes. She has rarely had this in the past.
Labs (4 days ago in ER) show:
1. Lipids: Total cholesterol 210, triglycerides 97, HDL 85, LDL 106.
Notably she presented to the emergency room four days ago with TIA-like symptoms. She describes sensory loss on the left side of her tongue, the left half of her face and the left upper extremity. This spontaneously resolved. Workup in the emergency department was negative. This included a CT scan of the head. She has had carotid Dopplers performed several years ago.
PHYSICAL EXAMINATION
VITAL SIGNS: BP 118/70, pulse is 71 and regular. Oxygen saturation is 93% on room air.
CONSTITUTIONAL: In no acute distress.
HEENT: Eyes: No xanthelasma or exophthalmos. No arcus senilis. Tongue midline. Mucous membranes moist, with no cyanosis.
RESPIRATORY: Respirations even and unlabored. Good air entry bilaterally. No
adventitious sounds. Chest has normal contour.
CARDIOVASCULAR: PMI normal. Neck veins flat. No carotid or subclavian bruits. S1, S2 and normal. No murmur, clicks or gallops. Abdominal aorta not palpable, no bruit. Femoral, tibial, dorsalis pedis pulses intact. No leg swelling.
GASTROINTESTINAL: Abdomen: Soft. Positive BS x4 quads. No tenderness or vascular masses. No hepatosplenomegaly.
SKIN: Pink, warm and dry. Skin intact. No rashes. No lesions. No clubbing or cyanosis.
NEUROLOGIC/PSYCH: Cranial nerves II-XII grossly intact. Alert and oriented x3. Affect normal.
ASSESSMENT:
1. New onset angina.
2. Suspected TIA.
3. Atherosclerotic heart disease
PLAN:
1. Proceed to left heart catheterization including coronary angiogram.
2. Up-titrate niacin as tolerated to 500 mg b.i.d. 3. She needs a carotid Doppler to evaluate for possible TIA symptoms.
Robert Jones, MD
Electronically signed by ROBERT JONES, MD 1/1/20XX
MEDICAL RECORD
OFFICE - NEW
Robert Jones, MD
CARDIOLOGY
SEX: Female
AGE: 73
Date: 01/01/20XX
PROBLEM LIST:
1. Patient is a retired registered nurse with history of brief rapid palpitations.
2. History of narcolepsy occurring 2-3 x/wk.
3. One episode of confusion. Told it was “temporary global amnesia,” July 20XX. No further episodes.
4. History of substance abuse with Benzodiazepine — none x several years.
5. History of obsessive compulsive disorder.
6. Lower extremity edema.
7. Restless leg syndrome.
ALLERGIES: Multiple statins aggravate her restless leg syndrome.
MEDICATIONS:
Klonopin 1.5 mg q.h.s. Neurontin 400-800 mg t.i.d. to max 3200 mg a day
Compounded estrogen q.d.
Vytorin 10/40 mg 1/2 to 1 tab q.a.m. Aspirin 81 mg q.d.
Lasix 20 mg p.r.n.
Calcium 1200 mg 3 x weekly
Multivitamins q.d.
B5 q.h.s. Amitiza 24 mcg b.i.d.
Folic acid t.i.d.
Comp9ound hormones
Melatonin 10 mg q.h.s. Niacin 250 mg b.i.d.
DHEA 12.5 mg q.a.m. Zofran 4 mg p.r.n. nausea
INTERVAL HISTORY: The patient had a CT scan of the chest to evaluate for pulmonary nodules.
CT chest (4 days ago in ER) shows:
1. This found extensive left coronary calcification, (atherosclerotic) which led to a stress echo today.
She notes that she has chest pain approximately a week to 10 days ago while watching the Olympics. She describes an anterior discomfort with no radiation and some difficulty breathing. This resolved spontaneously in 20 minutes. She has rarely had this in the past.
Labs (4 days ago in ER) show:
1. Lipids: Total cholesterol 210, triglycerides 97, HDL 85, LDL 106.
Notably she presented to the emergency room four days ago with TIA-like symptoms. She describes sensory loss on the left side of her tongue, the left half of her face and the left upper extremity. This spontaneously resolved. Workup in the emergency department was negative. This included a CT scan of the head. She has had carotid Dopplers performed several years ago.
PHYSICAL EXAMINATION
VITAL SIGNS: BP 118/70, pulse is 71 and regular. Oxygen saturation is 93% on room air.
CONSTITUTIONAL: In no acute distress.
HEENT: Eyes: No xanthelasma or exophthalmos. No arcus senilis. Tongue midline. Mucous membranes moist, with no cyanosis.
RESPIRATORY: Respirations even and unlabored. Good air entry bilaterally. No
adventitious sounds. Chest has normal contour.
CARDIOVASCULAR: PMI normal. Neck veins flat. No carotid or subclavian bruits. S1, S2 and normal. No murmur, clicks or gallops. Abdominal aorta not palpable, no bruit. Femoral, tibial, dorsalis pedis pulses intact. No leg swelling.
GASTROINTESTINAL: Abdomen: Soft. Positive BS x4 quads. No tenderness or vascular masses. No hepatosplenomegaly.
SKIN: Pink, warm and dry. Skin intact. No rashes. No lesions. No clubbing or cyanosis.
NEUROLOGIC/PSYCH: Cranial nerves II-XII grossly intact. Alert and oriented x3. Affect normal.
ASSESSMENT:
1. New onset angina.
2. Suspected TIA.
3. Atherosclerotic heart disease
PLAN:
1. Proceed to left heart catheterization including coronary angiogram.
2. Up-titrate niacin as tolerated to 500 mg b.i.d. 3. She needs a carotid Doppler to evaluate for possible TIA symptoms.
Robert Jones, MD
Electronically signed by ROBERT JONES, MD 1/1/20XX