using the 1995 guidelines.

daniel

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what level do you get out of this.
1995 guidlines only.'



This is a 70 y/o gentleman who has a H/O Atrial Fibrillation, Osteoarthritis,

HTN and Atherosclerosis.

CC: Chest Pain

HPI: Patient describes sharp pleuritic pain on the left side of the chest when climbing stairs and with
other activity. Pain started suddenly two days ago. Pain is generally continuous, but waxes and wanes
with significant increase in pain upon inspiration. Pain is non-radiating. It is associated with mild
diaphoresis and SOB. He has had a recent cough with periodic chills. Patient obtains best relief by
sitting quietly.

Medications include:
Digoxin 0.25 mg., po, OD
ASA 81 mg., po, OD
Atenolol 50 mg., po, BID
Motrin 200 mg., po, TID
Lasix 40 mg., po, OD

ROS:
Constitutuional: 4 lb. wt. loss; chills, as noted, with some night sweats
HEENT: No headaches, vision changes, nasal stuffiness or throat pain
CV: History of intermittent Atrial Fibrillation; no valvular disorder
Resp.: Recent cough, as noted: no H/O asthma or emphysema
GI: No dyspepsia, dysphagia; nausea at times; no vomiting; no
changes in bowel habits
GU: No incontinence, dysuria, nocturia; no change in urination
MS: Note generalized muscle weakness;(+) for knee pain with stairs;
no gout attacks; no recent leg trauma
Allergies: None
Neuro: No changes in mentation; neg. for focal pain, parasthesias or
extremity weakness
Skin: Notes warm, erythematous patch in right calf


PHYSICAL EXAM:
Constitutional: 150/90, Temp. 100, P. 110, Wt. 198 lbs.
HEENT: Conjunctiva clear, PERLA; tympanic membranes intact; fair
dental repair
Resp.: Fine rhonchi in lower left lobe, slight expiratory wheeze in the left
lower lobe; neg. for the use of accessory muscles; chest neg. for
deformity; palpation revealed mild left sided chest tenderness
CV: PMI is slightly displaced 2 fingerbreadths to the left of the midclavicular
line; S1 and S2 normal, intensity but irregular with a rate of
approximately 100; questionable S3 gallop present; moderately loud
apical systolic murmur; pedal pulses (+), femoral pulses are full; ankles
show 1 (+) edema
GI: B/S (+) in all 4 quadrants, no tenderness or mass palpated; liver and
spleen palpation normal; rectal area neg.; findings- stool sample neg. for
blood
MS: No clubbing of fingers, normal ROM in all extremities; no tenderness or
mass in joints; muscle strength 5/5; Homan's sign (+) rt. calf
Neuro: Alert, apprehensive; sensory –normal pinprick sensation; normal motor
exam; DTR's 2 (+); gait steady
GU: Prostate normal size; no penile discharge; no tenderness in scrotal area
Skin: No diaphoresis: warmth in rt. calf with tenderness
Psych: Appears appropriately anxious; answers questions coherently


ASSESSMENT:
EKG done today shows Atrial Fibrillation with ventricular response of 118. Diffuse ST-T changes nonspecic;
however, ST-T changes are more pronounced than prior tracing. A.Fib. has reoccurred after
stabilization for the prior 18 months. Pulse oximetry today show O2 saturation of 90%.
Echocardiography shows Left Ventricular Ejection Fraction of 45%. Some depression of right
ventricular function noted. There is a marked Tricuspid regurgitation with estimated pulmonary artery
pressure of 50 mm of mercury.
Probable acute pulmonary embolus, possible pneumonia, possible acute coronary syndrome.



MDM:
Nasal O2 @2L/min. continuous
Dilaudid 2 mg., IM for chest pain stat
ASA 81 mg., sublingual stat
Admit to hospital
 

smillar

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Local Chapter Officer
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Is this an initial hosp visit? If so, I would code a 99221. It is lacking the PFSH, I only see Past Medical History, no social and no family.
 
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