Could you please review this note and help me to determine what level of established E&M visit is appropriate?
REASON FOR VISIT
She was here for followup of hospitalization.
SUBJECTIVE
The patient is a 76-year-old retired RN with a history of diabetes, coronary disease, COPD, previous breast cancer, previous lung cancer, moderate aortic stenosis with recent hospitalization for a possible diverticular rupture versus ischemic bowel jejunal rupture here for further evaluation. Greater than 45 minutes were spent with this patient, predominantly in discussion.
Abdominal pain, jejunal rupture. Marie was initially admitted on August 6. She had significant abdominal pain. She had a CT scan performed, which did show an abscess. Initially this was thought to be secondary to diverticulitis. It was then realized it was most likely jejuna ischemia. She did see Dr. Harlow while she was in the hospital. Initially there was talk of doing surgery on Marie, but instead she had a drain placed. Currently she does not have any abdominal pain. She denies any fevers, chills, or sweats. She is extremely, fatigued, though, and feels like she has not been able to get pats this. She also wonders what initially caused the damage. She wonders if her Voltaren that she took along with the steroid injection that she had prior to the surgery could have done this. She also wonders if constipation could have made it worse.
She did call our office prior to going to the emergency room and had not received a call back. She was very upset about that. She also states that she called multiple times here. She had appointments and did not receive phone calls back, but when I speak with my nurses and staff, it is clear that she was called back so this is worrisome that she could also be confused.
Marie has a drain currently in place. They were going to take this out last week but she had too much drainage still and she was getting 10 mL of coffee-colored secretions still. She is wondering if she should stay on antibiotics. She does have the visiting nurses coming in to see her Monday, Wednesday, and Friday. They are flushing the drain at that time.
PAST MEDICAL HISTORY
Please see problem list.
MEDICATIONS
Medications are on the medication flow sheet.
OBJECTIVE
In general, she is alert. She does not look in distress.
Vital signs: Temperature 99.0, pulse 64, blood pressure 100/60. She is sitting in her wheelchair, does not look currently in distress but looks fatigued.
Cardiac exam: Normal S1, S2. Regular rate and rhythm. Soft systolic murmur. Lungs were clear today with decreased breath sounds.
Belly: Good active bowel sounds. The drain has a clean dressing over it.
Extremities: Her edema is much improved to, at most, 1+ in both of her ankles.
ASSESSMENT
Extended discussion with the patient today regarding her current status and also hospital and postop care.
PLAN
1. Previous abdominal pain, abscess. I will talk with Dr. Harlow or e-mail him regarding current and continued treatment for Marie. She will have her drain reassessed on September 8. She was told that the small bowel is adhering to her large bowel and I want to know if he would do anything differently. For now I will continue her on antibiotics, giving her another 10 days of Augmentin 875 mg twice daily and cefpodoxime 200 mg twice daily. I will ask him if he thinks the Voltaren and steroid injection could have done any damage, though I doubt this. I believe this is all secondary to ischemia. I will ask him if the constipation could have caused more problems. If necessary, we can get her in to see him again for further surgical evaluation.
2. I did give her a new prescription for 10 mL saline flush syringes.
3. I did stop the Neurontin as she did not have any back pain or radicular pain that she had previously.
4. I will have her follow up shortly after she has her drain reassessed on September 8.
Thank you
REASON FOR VISIT
She was here for followup of hospitalization.
SUBJECTIVE
The patient is a 76-year-old retired RN with a history of diabetes, coronary disease, COPD, previous breast cancer, previous lung cancer, moderate aortic stenosis with recent hospitalization for a possible diverticular rupture versus ischemic bowel jejunal rupture here for further evaluation. Greater than 45 minutes were spent with this patient, predominantly in discussion.
Abdominal pain, jejunal rupture. Marie was initially admitted on August 6. She had significant abdominal pain. She had a CT scan performed, which did show an abscess. Initially this was thought to be secondary to diverticulitis. It was then realized it was most likely jejuna ischemia. She did see Dr. Harlow while she was in the hospital. Initially there was talk of doing surgery on Marie, but instead she had a drain placed. Currently she does not have any abdominal pain. She denies any fevers, chills, or sweats. She is extremely, fatigued, though, and feels like she has not been able to get pats this. She also wonders what initially caused the damage. She wonders if her Voltaren that she took along with the steroid injection that she had prior to the surgery could have done this. She also wonders if constipation could have made it worse.
She did call our office prior to going to the emergency room and had not received a call back. She was very upset about that. She also states that she called multiple times here. She had appointments and did not receive phone calls back, but when I speak with my nurses and staff, it is clear that she was called back so this is worrisome that she could also be confused.
Marie has a drain currently in place. They were going to take this out last week but she had too much drainage still and she was getting 10 mL of coffee-colored secretions still. She is wondering if she should stay on antibiotics. She does have the visiting nurses coming in to see her Monday, Wednesday, and Friday. They are flushing the drain at that time.
PAST MEDICAL HISTORY
Please see problem list.
MEDICATIONS
Medications are on the medication flow sheet.
OBJECTIVE
In general, she is alert. She does not look in distress.
Vital signs: Temperature 99.0, pulse 64, blood pressure 100/60. She is sitting in her wheelchair, does not look currently in distress but looks fatigued.
Cardiac exam: Normal S1, S2. Regular rate and rhythm. Soft systolic murmur. Lungs were clear today with decreased breath sounds.
Belly: Good active bowel sounds. The drain has a clean dressing over it.
Extremities: Her edema is much improved to, at most, 1+ in both of her ankles.
ASSESSMENT
Extended discussion with the patient today regarding her current status and also hospital and postop care.
PLAN
1. Previous abdominal pain, abscess. I will talk with Dr. Harlow or e-mail him regarding current and continued treatment for Marie. She will have her drain reassessed on September 8. She was told that the small bowel is adhering to her large bowel and I want to know if he would do anything differently. For now I will continue her on antibiotics, giving her another 10 days of Augmentin 875 mg twice daily and cefpodoxime 200 mg twice daily. I will ask him if he thinks the Voltaren and steroid injection could have done any damage, though I doubt this. I believe this is all secondary to ischemia. I will ask him if the constipation could have caused more problems. If necessary, we can get her in to see him again for further surgical evaluation.
2. I did give her a new prescription for 10 mL saline flush syringes.
3. I did stop the Neurontin as she did not have any back pain or radicular pain that she had previously.
4. I will have her follow up shortly after she has her drain reassessed on September 8.
Thank you