NESmith
Guest
Please help with the coding of this visit
CC-Astma flare up x 1 week on & off. Has gotten worse,SOB
HPI-General overall felling severe fatigue x 1 week sudden moderate. Fever low grade fever on & off x 1 week gradual getting worse and chills. Chest pain or discomfort x 1 week gradual onset since asthma flare up. Pulmonary symptoms-Dyspnea due to difficulty taking a breath. Expressed feeling SOB and feelings of suffocation. Dry hacking cough and wheezing x 1 week. Symptoms of weakness and anixiety.
Provider records all three PFSH
ROS- Systemic-Fatigue, fever and chills
Cardio-see HPI
Pulmonary-see HPI
Gastro-No abdominal pain.
Endocrine-No excessive sweating
Neuro-see HPI
Exam-Pt was observed to be obese. General Appearance-use of acessory muscles in neck & abd. Oriented to time,place and person
Head-Normocephalic
Eyes-External eyelids showed no abnormalities. Conjunctivae of both eyes exhibited no abnormalities.
Lymph Nodes-Cervical lymph nodes: normal Supraclavicular-normal
Chest-Normal
Lungs-Abnormal breath sounds/voice sounds. Bilateral decrease was hard. Wheezing severe. Clear to auscultation. No rhonchi were heard. No rales/crackles were heard.
Cardiovascular-Heart Rate & Rhythm-normal Heart Sounds-normal S1 normal S2 normal
Murmurs-no murmurs were heard
Abdomen-Visual Inspection-Abdomen was not distended. Ausculation-Bowel sounds normal.Palpation-abdomen soft, no abdominal tenderness. Spleen-not palpable.
Neurological-Gait & Stance normal.
No edema
Assessment-Atypical chest pain.
Asthma with acute exacerbation
Wheezing
SOB
Therapy-Adminstered Kenalog 60 mg/ml Susp-No adverse effects @ 15 mins following injection
Administered Rocephin 1gm Solr-No adverse effects @ 15 mins follwoing injection
Counseling/Education-Intervention & counseling on cessation of tobacco use. Lose weight.
Plan-Asthma with Acute Exacerbation. order neb machine.
Nebulizer Treatment-Indication-SOB Medication Aministered: Albuterol 0.83% Pre Heart Rate: 84 Pre O2 Sat: 94%
Post Heart Rate:86
Post o2 Sat; 96%
Post Treatment Lung Sounds: Improved airway.
Follow-up 2-3 days.
Provider coding this a level 5.
Thank You for your help.
CC-Astma flare up x 1 week on & off. Has gotten worse,SOB
HPI-General overall felling severe fatigue x 1 week sudden moderate. Fever low grade fever on & off x 1 week gradual getting worse and chills. Chest pain or discomfort x 1 week gradual onset since asthma flare up. Pulmonary symptoms-Dyspnea due to difficulty taking a breath. Expressed feeling SOB and feelings of suffocation. Dry hacking cough and wheezing x 1 week. Symptoms of weakness and anixiety.
Provider records all three PFSH
ROS- Systemic-Fatigue, fever and chills
Cardio-see HPI
Pulmonary-see HPI
Gastro-No abdominal pain.
Endocrine-No excessive sweating
Neuro-see HPI
Exam-Pt was observed to be obese. General Appearance-use of acessory muscles in neck & abd. Oriented to time,place and person
Head-Normocephalic
Eyes-External eyelids showed no abnormalities. Conjunctivae of both eyes exhibited no abnormalities.
Lymph Nodes-Cervical lymph nodes: normal Supraclavicular-normal
Chest-Normal
Lungs-Abnormal breath sounds/voice sounds. Bilateral decrease was hard. Wheezing severe. Clear to auscultation. No rhonchi were heard. No rales/crackles were heard.
Cardiovascular-Heart Rate & Rhythm-normal Heart Sounds-normal S1 normal S2 normal
Murmurs-no murmurs were heard
Abdomen-Visual Inspection-Abdomen was not distended. Ausculation-Bowel sounds normal.Palpation-abdomen soft, no abdominal tenderness. Spleen-not palpable.
Neurological-Gait & Stance normal.
No edema
Assessment-Atypical chest pain.
Asthma with acute exacerbation
Wheezing
SOB
Therapy-Adminstered Kenalog 60 mg/ml Susp-No adverse effects @ 15 mins following injection
Administered Rocephin 1gm Solr-No adverse effects @ 15 mins follwoing injection
Counseling/Education-Intervention & counseling on cessation of tobacco use. Lose weight.
Plan-Asthma with Acute Exacerbation. order neb machine.
Nebulizer Treatment-Indication-SOB Medication Aministered: Albuterol 0.83% Pre Heart Rate: 84 Pre O2 Sat: 94%
Post Heart Rate:86
Post o2 Sat; 96%
Post Treatment Lung Sounds: Improved airway.
Follow-up 2-3 days.
Provider coding this a level 5.
Thank You for your help.
