Hello, can anyone help with this practicode question? Thank you
Dx I chose: I50.1; Z95.1; Z95.5
E/M I chose: 99223
Are these correct?
INPATIENT VISIT - INITIAL
SEX: Male
AGE: 83
Heart Failure Admission H&P *
DATE OF SERVICE: 1/1/20XX
Associated Diagnoses: Left ventricular heart failure.
Basic information
Source of history: Family member.
Present at bedside: Family member.
Referral source:
History limitation: None.
Chief Complaint
83 YO S/P CABG 1986, and 5 Y S/P coronary angioplasty stent.
2W SOB, weak. 1 D ago sustained anterior chest pain. To VA, troponin increased, sinus tachycardia, hypoxia, bilateral pleural effusions, RX ASA, Heparin, Digoxin. TX for management
Review of Systems
Constitutional: Fatigue. Decreased activity.
Eye: Negative.
Ears/Nose/Mouth/Throat: Chronic postnasal discharge.
Respiratory: Cough.
Cardiovascular: Tachycardia. Chest pain: Midsternal.
Gastrointestinal: Negative.
Genitourinary: Negative.
Hematology/Lymphatics: Negative.
Endocrine: Negative.
Immunologic: Negative.
Musculoskeletal: Negative.
Integumentary: Negative.
Neurologic: Prior TIAs.
Psychiatric: Negative.
All other systems are negative.
Health Status
Allergies
Allergies Reviewed.
Result type: Consultation Note - Physician
Result date: 01/01/ 20XX
Result status: Auth (Verified)
Result title: Heart Failure Admission H&P
Performed by:
Verified by:
Encounter info:
Current Medications:
Medications Reviewed.
Histories:
Procedure history:
No active procedure history items have been selected or recorded.
Physical Examination
VS/Measurements
Reviewed results: Vital Signs
General: Alert arid oriented.
Neck: No carotid bruit.
Respiratory: Lungs are clear to auscultation. Decreased air entry with fine rales left base.
Integumentary: 2+ bilateral SOA. Pulses intact.
Review / Management
Differential diagnoses: Non STEMI. CHF. Possible pneumonia.
Results review: Interpretation: Consistent with previous results.
Chest x-ray results: Consistent with pleural effusion.
Diagnostic findings: EKG N/S ST abn.
Cardiac monitor: Reveals a Sinus tachycardia.
Impression and Plan:
Diagnoses: Left ventricular heart failure
Orders:
Echo.
Integrilin.
Cardiac catheterization.
Robert Jones, MD
Electronically signed by ROBERT JONES, MD 1/1/20XX
Dx I chose: I50.1; Z95.1; Z95.5
E/M I chose: 99223
Are these correct?
INPATIENT VISIT - INITIAL
SEX: Male
AGE: 83
Heart Failure Admission H&P *
DATE OF SERVICE: 1/1/20XX
Associated Diagnoses: Left ventricular heart failure.
Basic information
Source of history: Family member.
Present at bedside: Family member.
Referral source:
History limitation: None.
Chief Complaint
83 YO S/P CABG 1986, and 5 Y S/P coronary angioplasty stent.
2W SOB, weak. 1 D ago sustained anterior chest pain. To VA, troponin increased, sinus tachycardia, hypoxia, bilateral pleural effusions, RX ASA, Heparin, Digoxin. TX for management
Review of Systems
Constitutional: Fatigue. Decreased activity.
Eye: Negative.
Ears/Nose/Mouth/Throat: Chronic postnasal discharge.
Respiratory: Cough.
Cardiovascular: Tachycardia. Chest pain: Midsternal.
Gastrointestinal: Negative.
Genitourinary: Negative.
Hematology/Lymphatics: Negative.
Endocrine: Negative.
Immunologic: Negative.
Musculoskeletal: Negative.
Integumentary: Negative.
Neurologic: Prior TIAs.
Psychiatric: Negative.
All other systems are negative.
Health Status
Allergies
Allergies Reviewed.
Result type: Consultation Note - Physician
Result date: 01/01/ 20XX
Result status: Auth (Verified)
Result title: Heart Failure Admission H&P
Performed by:
Verified by:
Encounter info:
Current Medications:
Medications Reviewed.
Histories:
Procedure history:
No active procedure history items have been selected or recorded.
Physical Examination
VS/Measurements
Reviewed results: Vital Signs
General: Alert arid oriented.
Neck: No carotid bruit.
Respiratory: Lungs are clear to auscultation. Decreased air entry with fine rales left base.
Integumentary: 2+ bilateral SOA. Pulses intact.
Review / Management
Differential diagnoses: Non STEMI. CHF. Possible pneumonia.
Results review: Interpretation: Consistent with previous results.
Chest x-ray results: Consistent with pleural effusion.
Diagnostic findings: EKG N/S ST abn.
Cardiac monitor: Reveals a Sinus tachycardia.
Impression and Plan:
Diagnoses: Left ventricular heart failure
Orders:
Echo.
Integrilin.
Cardiac catheterization.
Robert Jones, MD
Electronically signed by ROBERT JONES, MD 1/1/20XX
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