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Home visit and office visit same day, how do I code

nelstx2

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nurse goes to patients house to do a INR,
Patient ends up coming in to see dr same day in the afternoon.Never coded like this before Please help!!!! He is Medicare patient

Chief Complaint: f/u ED Sat/ Sun

History of Present Illness: Nurse Med Check: pt states he felt a hard pop in his ankle on Sat night. Norco 5-325 1-2 tabs q 6 hrs prn. His US is scheduled for December 26th at 1:00pm, 3 hr procedure. Pt is very sick to his stomach.
LEFT FOOT;the pt was lifting his heavy cat into the tub and felt a pop in left inner foot and severe pain;he want to the ED due to pain 3-4hrs after onset of pain;xrays were take and placed on noco 325/5 for pain;(1 qid):His left foot/leg felt cold to the touch per ED physician;HIs pain is improving but now has dyspepsia
DYSPEPSIA;onset last night --generalized nausea w/o emesis;appeitite is down this am but not prior;he attributes sx to the norco;He denies nsaid use as he is on coumadin.
HIs pain this pain is 3/10---yest 8-10/10;No elevating foot much;


Review of Systems: denies fever/chills;chest pain;no new sob/doe above baseline;his left foot does not feel cold to him

Past Medical History: MEDICAL ILLNESSES: Atrial fibrillation; ASCHD; candidiasis; cardiomyopathy/CHF; ED;HTN; lymphadentis; adenovirus infection;
R central retinal vein occlusion 9-98-pt. can't be off coumadin due to recurrence; Fecal incontinence; Hypothyroid; Chronic renal insufficiency; gout; sinusitis; pneumonia; bronchitis; venous tributary (branch) occlusion of retina; hyperlipidemia
pacemaker placed 2000
hernia repair,inguinal 10 yrs ago
h/o nephrolithiasis

Family History: heart disease
CA:brother ? type
HTN:?
ASCAD;mother/father/brothers

Social History: independently lives w/wife a former nurse
plays golf 5 days/week
Tobacco: Never smoker
[Tobacco: Never smoker]


Allergies: penicillin, sulfa drug, simvastatin, Lopid (Updated by LPN on 12/23/2013 10:11 AM)

Medications:
acetaminophen 650 mg oral tablet, extended release, prn
acetaminophen-oxyCODONE 325 mg-5 mg oral tablet, prn for pain
allopurinol 300 mg oral tablet, 1 po q day
aspirin 81 mg oral delayed release tablet, 1 po q day
Ativan 0.5 mg oral tablet, 1/2 tab q hs and may take 1/2 tab q during the day prn
Coreg 25 mg oral tablet, 1 po BID
digoxin 125 mcg (0.125 mg) oral tablet, 1 po q d
Fish Oil 1000 mg oral capsule, 6 po in divided doses per wife
fluticasone 0.05 mg/inh nasal spray, 1 spray per nare two times per day
furosemide 20 mg oral tablet, TAKE ONE TABLET BY MOUTH ONE TIME DAILY
Lasix 20 mg oral tablet, 1 po q day
lisinopril 20 mg oral tablet, 1 po BID
Norco 5 mg-325 mg oral tablet, 1-2 q 6 hrs prn
Ocean 0.65% nasal spray, 1 spray per nare every 2-3 hrs while awake
potassium chloride 10 mEq oral tablet, extended release, 1 po q day with Lasix
Synthroid 100 mcg (0.1 mg) oral tablet, 1 po qd
triamcinolone topical 0.1% cream, apply sparingly to affected area BID
Vitamin D3 1000 intl units oral capsule, 2 po q day
warfarin 1 mg oral tablet, TAKE ONE TABLET BY MOUTH DAILY AS NEEDED TO KEEP INR BETWEEN 2-3.
warfarin 5 mg oral tablet, TAKE ONE TABLET BY MOUTH ONE TIME DAILY
Zovirax Topical 5% cream, apply to lips 6 x/day for 7 days w/outbreak

Physical Examination: Wt: 179 lb Ht: 68.5 in BMI: 26.9 BP: 118/62 P: 72 RR: 18 Temp: 97.9F HC: SAT: Pain: PF (pre-bronchodilator): PF (post-bronchodilator): Other: O2 stat 98 on room air
The pt appears ill c/o upset stomach;
GENERAL: above
HEAD:atraumatic
NECK:supple;no adenopathy or th yroid enlargement;no bruits
OROPHARNYX: wnl
EARS;wnl;no cerumen
LUNGS: CTA but diminished in bases bilat;
HEART: RRR S1 S2 without murmers, thrills, rubs
ABDOMEN: soft;nontender;
BACK;nontener to percussion over CVA or spinous processes
EXTREMITIES:no cyanosis of Left foot LEg but it is is cool to touch from mid leg distally;Pulses(PT 1/6 c/w 2/6 on right foot):)not able to palp DP of left foot;painful over mid foot and medial ankle;;
NEURO:CN 2-12 intact;DTR's intact
MS:good ROM of large joints;no muscle pain w/ activity
PSYCH:alert;mood approp;
SKIN:no rashes or abnormal lesions.

INR yest was 2.1

Assessment & Plan:
# UNSPECIFIED DISORDER OF MUSCLE LIGAMENT AND FASCIA (728.9):likey ligament tear assoc w/ sprain of foot/ankle left foot;improving and suspect as the swelling is resolving internally his pain is less;
# OTHER SPECIFIED CIRCULATORY SYSTEM DISORDERS (459.89):as his distal leg/foot is cool to touch and diminished pulses c/w right foot/ankle suspect some impairment due to acute swelling assoc w/ injury;His CO /pressures are attenuated due to age/atrial fib which will exac sx
Instructions printed and provided to patient:
1):agree w/ US but not avail here until 3 days from now
I will talk w/ radiology and assess if CT w/ contrast will suffice to determine vascular disruption w/ compression(pt is on coumadin): vs vascular compromise due to swelling/inflammation
2):suggest plain tylenol 1-2 q 4-6hrs intead of norco to see if GI sx improved
3):left foot above heart 2hrs bid
4):I will check on pt tommorrow;
5

**********


radiology consult for approx study :
we do not have US avail until 26th;discussed w/ Dr XXXX and he agrees w/ CT w/ contrast and runoff studies;
Signed by:
 
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