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The documentation:
Why are I49.3, I25.10, and Z95.5 reported but not the Plavix and aspirin? Are the former relevant to the patient's Metroprolol increase and the need for an echo, but not the latter?
OFFICE - ESTABLISHED
CARDIOLOGY
SEX: Male
AGE: 77
Date: 01/01/20XX
CHIEF CONCERN: He is here for medication check.
PROBLEM LIST
1. Single-vessel coronary artery disease with mid-distal LAD stent (0X/01/20XX).
2. Cardiomyopathy, ejection fraction 40%.
3. Left bundle branch block.
4. Hypertension.
5. Mitral valve prolapse.
ALLERGIES: No known drug allergies.
MEDICATIONS
Benicar HCT 20/12.5 mg q.d.
Aspirin 81 mg q.d.
Metoprolol ER 37.5 mg q.d.
Plavix 75 mg q.d.
INTERVAL HISTORY: At last office visit, a stress echocardiogram was equivocal for ischemia. He therefore proceeded to a nuclear stress test that showed no evidence of ischemia. Specifically, there was normal perfusion to inferior wall. His metoprolol was increased to 37.5 mg q.d. He has had no lightheadedness, dizziness or palpitations. No chest pain or shortness of breath. Blood pressure is well-controlled. He has returned to his previous level of exercise, which includes riding his bicycle 15 to 20 minutes daily.
PHYSICAL EXAMINATION
VITAL SIGNS: Weight 140 lbs. BP 122/62 in the left arm, pulse 62 and regular, oxygen saturation 96% on room air.
CONSTITUTIONAL: Respirations even and unlabored. Skin pink, warm and dry. He is in no 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 bruits. S1, S2 are 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 masses or tenderness. No hepatosplenomegaly.
SKIN: Right groin puncture site is well-healed. Skin is otherwise pink, warm, dry and intact. No rashes. No clubbing or cyanosis.
NEUROLOGIC/PSYCH: Cranial nerves II-XII grossly intact. Grips and pushes strong and equal bilaterally. Alert and oriented x3. Affect normal.
ASSESSMENT
1. Well-tolerated increased metoprolol dose given for increased PVCs at stress test
2. Equivocal stress echocardiogram without evidence of ischemia per nuclear stress test
PLAN
1. Increase exercise to 30 minutes a day five days a week.
2. The patient defers cardiac rehabilitation for now.
3. Echo and office visit at six months.
Robert Jones, MD
Electronically signed by ROBERT JONES, MD 1/1/20XX
CARDIOLOGY
SEX: Male
AGE: 77
Date: 01/01/20XX
CHIEF CONCERN: He is here for medication check.
PROBLEM LIST
1. Single-vessel coronary artery disease with mid-distal LAD stent (0X/01/20XX).
2. Cardiomyopathy, ejection fraction 40%.
3. Left bundle branch block.
4. Hypertension.
5. Mitral valve prolapse.
ALLERGIES: No known drug allergies.
MEDICATIONS
Benicar HCT 20/12.5 mg q.d.
Aspirin 81 mg q.d.
Metoprolol ER 37.5 mg q.d.
Plavix 75 mg q.d.
INTERVAL HISTORY: At last office visit, a stress echocardiogram was equivocal for ischemia. He therefore proceeded to a nuclear stress test that showed no evidence of ischemia. Specifically, there was normal perfusion to inferior wall. His metoprolol was increased to 37.5 mg q.d. He has had no lightheadedness, dizziness or palpitations. No chest pain or shortness of breath. Blood pressure is well-controlled. He has returned to his previous level of exercise, which includes riding his bicycle 15 to 20 minutes daily.
PHYSICAL EXAMINATION
VITAL SIGNS: Weight 140 lbs. BP 122/62 in the left arm, pulse 62 and regular, oxygen saturation 96% on room air.
CONSTITUTIONAL: Respirations even and unlabored. Skin pink, warm and dry. He is in no 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 bruits. S1, S2 are 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 masses or tenderness. No hepatosplenomegaly.
SKIN: Right groin puncture site is well-healed. Skin is otherwise pink, warm, dry and intact. No rashes. No clubbing or cyanosis.
NEUROLOGIC/PSYCH: Cranial nerves II-XII grossly intact. Grips and pushes strong and equal bilaterally. Alert and oriented x3. Affect normal.
ASSESSMENT
1. Well-tolerated increased metoprolol dose given for increased PVCs at stress test
2. Equivocal stress echocardiogram without evidence of ischemia per nuclear stress test
PLAN
1. Increase exercise to 30 minutes a day five days a week.
2. The patient defers cardiac rehabilitation for now.
3. Echo and office visit at six months.
Robert Jones, MD
Electronically signed by ROBERT JONES, MD 1/1/20XX
Why are I49.3, I25.10, and Z95.5 reported but not the Plavix and aspirin? Are the former relevant to the patient's Metroprolol increase and the need for an echo, but not the latter?