mklimm
New
New/inexperienced coder help for E/M ED visit- Can anyone explain why this would be considered low MDM and an acute uncomplicated illness instead of a chronic illness that is worsening if it states in the note it started 3-4 months ago and has been waxing and waning? Now patient is presenting with nausea, vomiting, loss of appetite. It literally says in the HPI " These are chronic" What is technically considered chronic or acute- is there a specific length of time? See note below:
-Michelle K.
MEDICAL RECORD
Emergency Department
Sex: F
AGE: 30
DOS: 1/1/20XX
Arrived- By private vehicle. Historian- patient.
HISTORY OF PRESENT ILLNESS
Chief complaint- ABDOMINAL PAIN, NAUSEA and VOMITING. This started about 3 - 4 months ago and is still present. It is not improving. It was gradual in onset and has been waxing/waning. It is described as burning and it is described as located in the epigastric 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. She has had nausea, loss of appetite and vomiting. No diarrhea.
No additional abdominal pain.
(s/p recent EGD in MT several mo ago, told she has erosions but not given any meds??).
Similar symptoms previously: She has had similar symptoms previously. These are chronic.
Recent medical care: Not recently seen/assessed.
REVIEW OF SYSTEMS
No constipation, black stools, hematemesis, difficulty with urination or pain with urination. No urinary frequency, bloody stools, fever, headache or sore throat. No blurred vision, chest pain, difficulty breathing, cough or joint pain. No skin rash, chills or back pain. Denies current pregnancy. The patient has not had weight loss. All systems otherwise negative, except as recorded above.
PAST HISTORY
Gastritis. Gastroesophageal reflux. Anxiety.
Denies the following risk factors for ectopic pregnancy - current IUD and history of infertility, PID, tubal ligation and prior ectopic. Denies the following risk factors for ectopic pregnancy - elective abortion within the last two weeks.
Surgeries: No history of previous surgery.
Medications: Mood Stabilizer.
Allergies: NKDA.
SOCIAL HISTORY: No alcohol use or drug use.
PHYSICAL EXAM
Appearance: Alert. Oriented X3. O2 sat monitor on the patient. Anxious. Appears to be in pain. Patient in moderate distress.
Vital Signs: Have been reviewed (BP: 138 / 70. HR: 80. RR: 16. Temp: 98.7. O2 saturation: room air -100 percent).
Eyes: Pupils equal, round and reactive to light. Eyes normal inspection.
ENT: Pharynx normal.
Neck: Normal inspection. Neck supple.
CVS: Normal heart rate and rhythm. Heart sounds normal.
Respiratory: No respiratory distress. Breath sounds normal. Chest nontender.
Abdomen: Soft. Moderate tenderness in the epigastric area. Bowel sounds normal. No organomegaly. No mass. Femoral pulses equal. No rebound tenderness or guarding.
Back: Normal inspection. No CVA tenderness.
Skin: Skin warm and dry. Normal skin color. No rash. Normal skin turgor.
Extremities: Extremities exhibit normal ROM. No lower extremity edema.
Neuro: Oriented X 3. No motor deficit. No sensory deficit.
LABS, X-RAYS, AND EKG
Rhythm Strip: Normal sinus rhythm.
Abdominal Sonogram: Normal right upper quadrant ultrasound.
Laboratory Tests: Laboratory tests have been ordered, with results reviewed and considered in the medical decision making process.
PROGRESS AND PROCEDURES
Course of Care: upper abd pain w/ hx ugi problems for yrs
IV fluids given. Zofran given. Given Protonix.
Dilaudid given.
Patient counseled in person regarding the patient's stable condition, test results, diagnosis and need for additional testing and follow-up.
Medical Decision Making: Serious or life threatening conditions must be ruled out as a cause for the patient's findings. The differential diagnosis includes, but is not limited to, appendicitis, perforated viscous, bowel obstruction, diverticulitis and ulcerative colitis. The presentation was not acute. The exam did not reveal vital signs that were significantly abnormal, McBurney's point tenderness or a positive Murphy's sign.
Ordered tests include an ultrasound of the gallbladder and labs.
No significant abnormalities were noted on the tests reviewed.
The patient has been stable during the ED course. The pain, vomiting and exam got better.
rec pmd f/u and gi referral as outpt
CONTINUE TAKING THE FOLLOWING MEDICATIONS:
Protonix
Percocet
Zofran
Rx for ppi, pain and nausea meds.
CLINICAL IMPRESSION:
Nausea and Vomiting
Chronic epigastric abdominal pain of unknown cause.
Probable gastritis.
Probable gastroesophageal reflux disease. Clinical picture does not suggest cholecystitis or pancreatitis.
Disposition: Condition: good and stable. Discharged.
Understanding of the discharge instructions verbalized by patient.
Adam Kramer, MD
Electronically signed by ADAM KRAMER, MD 1/1/20XX
-Michelle K.
MEDICAL RECORD
Emergency Department
Sex: F
AGE: 30
DOS: 1/1/20XX
Arrived- By private vehicle. Historian- patient.
HISTORY OF PRESENT ILLNESS
Chief complaint- ABDOMINAL PAIN, NAUSEA and VOMITING. This started about 3 - 4 months ago and is still present. It is not improving. It was gradual in onset and has been waxing/waning. It is described as burning and it is described as located in the epigastric 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. She has had nausea, loss of appetite and vomiting. No diarrhea.
No additional abdominal pain.
(s/p recent EGD in MT several mo ago, told she has erosions but not given any meds??).
Similar symptoms previously: She has had similar symptoms previously. These are chronic.
Recent medical care: Not recently seen/assessed.
REVIEW OF SYSTEMS
No constipation, black stools, hematemesis, difficulty with urination or pain with urination. No urinary frequency, bloody stools, fever, headache or sore throat. No blurred vision, chest pain, difficulty breathing, cough or joint pain. No skin rash, chills or back pain. Denies current pregnancy. The patient has not had weight loss. All systems otherwise negative, except as recorded above.
PAST HISTORY
Gastritis. Gastroesophageal reflux. Anxiety.
Denies the following risk factors for ectopic pregnancy - current IUD and history of infertility, PID, tubal ligation and prior ectopic. Denies the following risk factors for ectopic pregnancy - elective abortion within the last two weeks.
Surgeries: No history of previous surgery.
Medications: Mood Stabilizer.
Allergies: NKDA.
SOCIAL HISTORY: No alcohol use or drug use.
PHYSICAL EXAM
Appearance: Alert. Oriented X3. O2 sat monitor on the patient. Anxious. Appears to be in pain. Patient in moderate distress.
Vital Signs: Have been reviewed (BP: 138 / 70. HR: 80. RR: 16. Temp: 98.7. O2 saturation: room air -100 percent).
Eyes: Pupils equal, round and reactive to light. Eyes normal inspection.
ENT: Pharynx normal.
Neck: Normal inspection. Neck supple.
CVS: Normal heart rate and rhythm. Heart sounds normal.
Respiratory: No respiratory distress. Breath sounds normal. Chest nontender.
Abdomen: Soft. Moderate tenderness in the epigastric area. Bowel sounds normal. No organomegaly. No mass. Femoral pulses equal. No rebound tenderness or guarding.
Back: Normal inspection. No CVA tenderness.
Skin: Skin warm and dry. Normal skin color. No rash. Normal skin turgor.
Extremities: Extremities exhibit normal ROM. No lower extremity edema.
Neuro: Oriented X 3. No motor deficit. No sensory deficit.
LABS, X-RAYS, AND EKG
Rhythm Strip: Normal sinus rhythm.
Abdominal Sonogram: Normal right upper quadrant ultrasound.
Laboratory Tests: Laboratory tests have been ordered, with results reviewed and considered in the medical decision making process.
PROGRESS AND PROCEDURES
Course of Care: upper abd pain w/ hx ugi problems for yrs
IV fluids given. Zofran given. Given Protonix.
Dilaudid given.
Patient counseled in person regarding the patient's stable condition, test results, diagnosis and need for additional testing and follow-up.
Medical Decision Making: Serious or life threatening conditions must be ruled out as a cause for the patient's findings. The differential diagnosis includes, but is not limited to, appendicitis, perforated viscous, bowel obstruction, diverticulitis and ulcerative colitis. The presentation was not acute. The exam did not reveal vital signs that were significantly abnormal, McBurney's point tenderness or a positive Murphy's sign.
Ordered tests include an ultrasound of the gallbladder and labs.
No significant abnormalities were noted on the tests reviewed.
The patient has been stable during the ED course. The pain, vomiting and exam got better.
rec pmd f/u and gi referral as outpt
CONTINUE TAKING THE FOLLOWING MEDICATIONS:
Protonix
Percocet
Zofran
Rx for ppi, pain and nausea meds.
CLINICAL IMPRESSION:
Nausea and Vomiting
Chronic epigastric abdominal pain of unknown cause.
Probable gastritis.
Probable gastroesophageal reflux disease. Clinical picture does not suggest cholecystitis or pancreatitis.
Disposition: Condition: good and stable. Discharged.
Understanding of the discharge instructions verbalized by patient.
Adam Kramer, MD
Electronically signed by ADAM KRAMER, MD 1/1/20XX