peanutbutterkisses
Contributor
Good morning,
I wanted a second opinion about this chart. What would you say is the Cheif Complaint? How would you code this chart?
INTERIM HISTORY:
This is an 68 year old male with history significant for CAD, DM2,
HTN, atrial fibrillation on warfarin, PVD s/p L AKA, vascular dementia, and
neurogenic bladder + BPH, with recent admissions for colonic pseudo-obstruction.
Vet has recently been treated for recurrent uti and has indwelling catheter. Vet
has recently been given a motorized scooter and is very happy. Mood has
improved.
_______________________________________________________________________
REVIEW OF SYSTEMS:
Vet has no complaints, denies sob, cp, palpitations, n/v or
diarrhea/constipation.
_______________________________________________________________________
Medications dispensed from VA facilities.
Non VA medications as documented and/or reported by patient/surrogate:
==================================================================
Active Inpatient and Outpatient Medications (including Supplies):
Inpatient Medications Status
=========================================================================
1) ACETAMINOPHEN TAB 650MG PO Q6H PRN Administer as ACTIVE
needed for Mild pain (pain score 1-4)
2) ARTIFICIAL TEARS SOLN,OPH 2 DROPS OU Q4HA PRN may ACTIVE
refuse dry eye
3) ATENOLOL TAB 50MG PO QDAY Hold for SYSTOLIC BLOOD ACTIVE
PRESSURE <110 and HR <60
4) ATORVASTATIN TAB 40MG PO QHS ACTIVE
5) CALAMINE/LANOLIN/MENTHOL/ZINC OXIDE SMALL AMOUNT TOP ACTIVE
TID PRN excoriation
6) CITALOPRAM HBr TAB 20MG PO QDAY ACTIVE
7) FINASTERIDE (DO NOT CRUSH) TAB 5MG PO QDAY ACTIVE
CHILDBEARING AGE FEMALE HANDLE WITH CAUTION *
HANDLE WITH GLOVES
8) HYDROXYZINE TAB 25MG PO Q6H PRN pruritus ACTIVE
9) LISINOPRIL TAB 5MG PO QDAY ACTIVE
10) POLYETHYLENE GLYCOL POWDER,ORAL 1 PACKET (17GM) PO ACTIVE
QDAILY PRN
11) POTASSIUM CHL (K-DUR) TAB,SA 40MEQ PO BID ACTIVE
12) PSYLLIUM (SUGAR-FREE) POWDER,ORAL 1 PACKET PO DAILY ACTIVE
13) QUETIAPINE FUMARATE TAB 25MG PO Q4H PRN Max: 3 prn ACTIVE
doses Q 24hours; for agitaion/combativeness
14) SENNA (187MG [8.6MG SENNOSIDES]) TAB 17.2MG PO ACTIVE
TU-TH-SA@HS PRN
15) TAMSULOSIN CAP,ORAL 0.4MG PO DAILY ACTIVE
16) THIAMINE TAB 100MG PO QDAY ACTIVE
17) WARFARIN (HIGH RISK) TAB 5MG PO D5 start 1/8 No ACTIVE
coumadin today 1/7
Outpatient Medications Status
=========================================================================
1) ATENOLOL 50MG TAB TAKE ONE TABLET BY MOUTH EVERY DAY HOLD
FOR HEART
2) FOLIC ACID 1MG TAB TAKE ONE TABLET BY MOUTH EVERY DAY HOLD
3) FUROSEMIDE 40MG TAB TAKE ONE TABLET BY MOUTH EVERY HOLD
MORNING
4) GAUZE,PACKING IODOFORM 1/2IN X 5YD USE GAUZE HOLD
TOPICALLY EVERY DAY LIGHTLY PACK WOUND FROM LATERAL
SIDE.
5) NICOTINE 14MG/24HR PATCH APPLY ONE PATCH TOPICALLY HOLD
EVERY DAY AFTER REMOVING OLD PATCH (FOR EXTERNAL
USE ONLY)
6) TAPE,DURAPORE 1IN 3M #1538-1 TAPE EVERY DAY (FOR HOLD
EXTERNAL USE)
7) TRAZODONE HCL 50MG TAB TAKE ONE TABLET BY MOUTH AT HOLD
BEDTIME
24 Total Medications
==================================================================
No Active Remote Medications for this patient
PHYSICAL EXAMINATION:
Gen: awake and alert, no acute distress
HEENT: EOMI, no lymphadenopathy, moist mucosa
Lungs: cta
Heart: rrr
Abd: snt, +bs
Ext: no peripheral edema
Skin: intact
97.2 74 17 123/75 91%RA
_______________________________________________________________________
RECENT LABORATORY:
INR-2.5
_______________________________________________________________________
RECENT CONSULTS:
Dental, psych-started on quetiapine prn and rehab seating
_______________________________________________________________________
ASSESSMENT/PLAN:
Left aka-will monitor scooter use, consult placed for gel chair
frequent uti-monitor s/s
afib-inr therapeutic, for recheck next week.
code status to remain dnr
I wanted a second opinion about this chart. What would you say is the Cheif Complaint? How would you code this chart?
INTERIM HISTORY:
This is an 68 year old male with history significant for CAD, DM2,
HTN, atrial fibrillation on warfarin, PVD s/p L AKA, vascular dementia, and
neurogenic bladder + BPH, with recent admissions for colonic pseudo-obstruction.
Vet has recently been treated for recurrent uti and has indwelling catheter. Vet
has recently been given a motorized scooter and is very happy. Mood has
improved.
_______________________________________________________________________
REVIEW OF SYSTEMS:
Vet has no complaints, denies sob, cp, palpitations, n/v or
diarrhea/constipation.
_______________________________________________________________________
Medications dispensed from VA facilities.
Non VA medications as documented and/or reported by patient/surrogate:
==================================================================
Active Inpatient and Outpatient Medications (including Supplies):
Inpatient Medications Status
=========================================================================
1) ACETAMINOPHEN TAB 650MG PO Q6H PRN Administer as ACTIVE
needed for Mild pain (pain score 1-4)
2) ARTIFICIAL TEARS SOLN,OPH 2 DROPS OU Q4HA PRN may ACTIVE
refuse dry eye
3) ATENOLOL TAB 50MG PO QDAY Hold for SYSTOLIC BLOOD ACTIVE
PRESSURE <110 and HR <60
4) ATORVASTATIN TAB 40MG PO QHS ACTIVE
5) CALAMINE/LANOLIN/MENTHOL/ZINC OXIDE SMALL AMOUNT TOP ACTIVE
TID PRN excoriation
6) CITALOPRAM HBr TAB 20MG PO QDAY ACTIVE
7) FINASTERIDE (DO NOT CRUSH) TAB 5MG PO QDAY ACTIVE
CHILDBEARING AGE FEMALE HANDLE WITH CAUTION *
HANDLE WITH GLOVES
8) HYDROXYZINE TAB 25MG PO Q6H PRN pruritus ACTIVE
9) LISINOPRIL TAB 5MG PO QDAY ACTIVE
10) POLYETHYLENE GLYCOL POWDER,ORAL 1 PACKET (17GM) PO ACTIVE
QDAILY PRN
11) POTASSIUM CHL (K-DUR) TAB,SA 40MEQ PO BID ACTIVE
12) PSYLLIUM (SUGAR-FREE) POWDER,ORAL 1 PACKET PO DAILY ACTIVE
13) QUETIAPINE FUMARATE TAB 25MG PO Q4H PRN Max: 3 prn ACTIVE
doses Q 24hours; for agitaion/combativeness
14) SENNA (187MG [8.6MG SENNOSIDES]) TAB 17.2MG PO ACTIVE
TU-TH-SA@HS PRN
15) TAMSULOSIN CAP,ORAL 0.4MG PO DAILY ACTIVE
16) THIAMINE TAB 100MG PO QDAY ACTIVE
17) WARFARIN (HIGH RISK) TAB 5MG PO D5 start 1/8 No ACTIVE
coumadin today 1/7
Outpatient Medications Status
=========================================================================
1) ATENOLOL 50MG TAB TAKE ONE TABLET BY MOUTH EVERY DAY HOLD
FOR HEART
2) FOLIC ACID 1MG TAB TAKE ONE TABLET BY MOUTH EVERY DAY HOLD
3) FUROSEMIDE 40MG TAB TAKE ONE TABLET BY MOUTH EVERY HOLD
MORNING
4) GAUZE,PACKING IODOFORM 1/2IN X 5YD USE GAUZE HOLD
TOPICALLY EVERY DAY LIGHTLY PACK WOUND FROM LATERAL
SIDE.
5) NICOTINE 14MG/24HR PATCH APPLY ONE PATCH TOPICALLY HOLD
EVERY DAY AFTER REMOVING OLD PATCH (FOR EXTERNAL
USE ONLY)
6) TAPE,DURAPORE 1IN 3M #1538-1 TAPE EVERY DAY (FOR HOLD
EXTERNAL USE)
7) TRAZODONE HCL 50MG TAB TAKE ONE TABLET BY MOUTH AT HOLD
BEDTIME
24 Total Medications
==================================================================
No Active Remote Medications for this patient
PHYSICAL EXAMINATION:
Gen: awake and alert, no acute distress
HEENT: EOMI, no lymphadenopathy, moist mucosa
Lungs: cta
Heart: rrr
Abd: snt, +bs
Ext: no peripheral edema
Skin: intact
97.2 74 17 123/75 91%RA
_______________________________________________________________________
RECENT LABORATORY:
INR-2.5
_______________________________________________________________________
RECENT CONSULTS:
Dental, psych-started on quetiapine prn and rehab seating
_______________________________________________________________________
ASSESSMENT/PLAN:
Left aka-will monitor scooter use, consult placed for gel chair
frequent uti-monitor s/s
afib-inr therapeutic, for recheck next week.
code status to remain dnr