Elund
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The documentation:
Why should the diabetes be reported as a diagnosis when it was only mentioned in the past history?
EMERGENCY DEPARTMENT
SEX: FEMALE
AGE: 79
DOS: 1/1/20XX
Initial patient contact.
Arrived- By private vehicle. Historian- patient.
Code only for the Emergency Department
HISTORY OF PRESENT ILLNESS
Chief complaint- DYSPNEA and HISTORY OF CONGESTIVE HEART FAILURE. This started about 1 weeks ago and is still present. The dyspnea is described as moderate. The dyspnea is worsened by walking and exertion, is improved by rest and is improved with sitting upright. She has had dyspnea on exertion, orthopnea and paroxysmal nocturnal dyspnea. No cough, sputum production, fever, sweating episodes or wheezing. No chest pain or discomfort, calf pain, foot swelling or anxiety. No dizziness, tingling, numbness or palpitations. This is a female with hx of CAD, CABG, ischemic cardiomyopathy with CHF requiring pacemaker presents with worsening dyspnea over last week. Pt has had DOE, orthopnea, PND and increased leg swelling. Pt denies any chest pain, no fevers, no cough. Similar symptoms previously: She has had similar symptoms several times previously. These were milder.
Recent medical care: Not recently seen/assessed.
REVIEW OF SYSTEMS: The patient has not had weight loss. No muscle aches, eye irritation, sore throat, nasal discharge or sinus drainage. No nausea, vomiting, abdominal pain, diarrhea or black stools. No headache, fainting episodes, difficulty with urination, skin rash or enlarged lymph nodes. All systems otherwise negative, except as recorded above.
PAST HISTORY
Hypertension. Diabetes mellitus. Heart disease.
Surgeries: Coronary artery bypass graft surgery. Mastectomy. Pacemaker.
SOCIAL HISTORY: Nonsmoker. No alcohol use or drug use. No recent travel.
FAMILY HISTORY: Negative.
PHYSICAL EXAM
Appearance: Alert. Patient in mild distress.
Vital Signs: Have been reviewed- hypertensive; heart rate normal; respiratory rate normal and oxygen saturation low; temperature normal (BP: 145/75 sitting L arm auto (reg adult cuff). HR: 87. RR: 22 (regular and labored). Temp: 97.8 F (temporal). O2 saturation: on oxygen, decreased with talking to 91% -97 percent and -94 percent on nasal cannula at 2 liter/minute.).
Eyes: Pupils equal, round and reactive to light.
ENT: Nose normal. Pharynx normal.
Neck: Normal inspection. 2 cm of JVD present. Neck supple.
CVS: Normal heart rate and rhythm. 2/6 brief, mid systolic murmur. Pulses normal.
Respiratory: Mild respiratory distress with accessory muscle use. Mild rales present in the bases bilaterally. No decreased air movement, prolonged expiration or wheezes.
Abdomen: Soft and nontender. No organomegaly. Distention (mild).
Back: Normal inspection.
Skin: Skin warm. Normal skin color. No rash.
Extremities: Bilateral moderate 2+ pitting edema of the lower extremities involving both feet, both ankles and both lower legs. Extremities exhibit normal ROM.
Neuro: Oriented X 3. No motor deficit. No sensory deficit.
LABS, X-RAYS, AND EKG
EKG: No acute ischemia. Rate: 78. Continuous ventricular paced rhythm.
Chest X-ray: Changes from prior cardiac surgery and pacer placement again noted. Heart diffusely enlarged. Mediastinum unchanged. Vascular congestion with small bilateral pleural effusions. No pneumothorax.
PROGRESS AND PROCEDURES
Clinical Review The diagnosis of Acute Coronary Syndrome in this patient is unlikely.
ECG interpretation documented.
Consultation obtained from cardiologist.
Chest pain precautions provided to patient and family.
Course of Care: Female with worsening CHF exacerbation. Doubt ACS or PE given no chest pain and not tachycardic. Pt's CXR consistent with CHF and BNP elevated. Spoke with Dr. Thomas for Dr. Jones who agreed to admit pt to PCU. Pt given IV Lasix and diuresed over 1 liter, still slightly hypoxic when taken off O2 though, down to upper 80's. Pt appears stable for PCU admission though.
CONCLUSIONS: Changes suggest mild congestive failure. A comparison with prior films reveals that the findings are new.
Patient and family counseled in person many times regarding the patient's stable condition, test results, diagnosis and need for additional testing, admission and follow-up. Old ED and inpatient records reviewed.
Phone consult obtained from cardiology. Will see patient in the hospital today.
Disposition: Admitted to Progressive Care Unit. Condition: stable.
CLINICAL IMPRESSION
Dyspnea.
Acute moderate congestive heart failure.
John Kramer, MD
Electronically signed by JOHN KRAMER, MD 1/1/20XX
SEX: FEMALE
AGE: 79
DOS: 1/1/20XX
Initial patient contact.
Arrived- By private vehicle. Historian- patient.
Code only for the Emergency Department
HISTORY OF PRESENT ILLNESS
Chief complaint- DYSPNEA and HISTORY OF CONGESTIVE HEART FAILURE. This started about 1 weeks ago and is still present. The dyspnea is described as moderate. The dyspnea is worsened by walking and exertion, is improved by rest and is improved with sitting upright. She has had dyspnea on exertion, orthopnea and paroxysmal nocturnal dyspnea. No cough, sputum production, fever, sweating episodes or wheezing. No chest pain or discomfort, calf pain, foot swelling or anxiety. No dizziness, tingling, numbness or palpitations. This is a female with hx of CAD, CABG, ischemic cardiomyopathy with CHF requiring pacemaker presents with worsening dyspnea over last week. Pt has had DOE, orthopnea, PND and increased leg swelling. Pt denies any chest pain, no fevers, no cough. Similar symptoms previously: She has had similar symptoms several times previously. These were milder.
Recent medical care: Not recently seen/assessed.
REVIEW OF SYSTEMS: The patient has not had weight loss. No muscle aches, eye irritation, sore throat, nasal discharge or sinus drainage. No nausea, vomiting, abdominal pain, diarrhea or black stools. No headache, fainting episodes, difficulty with urination, skin rash or enlarged lymph nodes. All systems otherwise negative, except as recorded above.
PAST HISTORY
Hypertension. Diabetes mellitus. Heart disease.
Surgeries: Coronary artery bypass graft surgery. Mastectomy. Pacemaker.
SOCIAL HISTORY: Nonsmoker. No alcohol use or drug use. No recent travel.
FAMILY HISTORY: Negative.
PHYSICAL EXAM
Appearance: Alert. Patient in mild distress.
Vital Signs: Have been reviewed- hypertensive; heart rate normal; respiratory rate normal and oxygen saturation low; temperature normal (BP: 145/75 sitting L arm auto (reg adult cuff). HR: 87. RR: 22 (regular and labored). Temp: 97.8 F (temporal). O2 saturation: on oxygen, decreased with talking to 91% -97 percent and -94 percent on nasal cannula at 2 liter/minute.).
Eyes: Pupils equal, round and reactive to light.
ENT: Nose normal. Pharynx normal.
Neck: Normal inspection. 2 cm of JVD present. Neck supple.
CVS: Normal heart rate and rhythm. 2/6 brief, mid systolic murmur. Pulses normal.
Respiratory: Mild respiratory distress with accessory muscle use. Mild rales present in the bases bilaterally. No decreased air movement, prolonged expiration or wheezes.
Abdomen: Soft and nontender. No organomegaly. Distention (mild).
Back: Normal inspection.
Skin: Skin warm. Normal skin color. No rash.
Extremities: Bilateral moderate 2+ pitting edema of the lower extremities involving both feet, both ankles and both lower legs. Extremities exhibit normal ROM.
Neuro: Oriented X 3. No motor deficit. No sensory deficit.
LABS, X-RAYS, AND EKG
EKG: No acute ischemia. Rate: 78. Continuous ventricular paced rhythm.
Chest X-ray: Changes from prior cardiac surgery and pacer placement again noted. Heart diffusely enlarged. Mediastinum unchanged. Vascular congestion with small bilateral pleural effusions. No pneumothorax.
PROGRESS AND PROCEDURES
Clinical Review The diagnosis of Acute Coronary Syndrome in this patient is unlikely.
ECG interpretation documented.
Consultation obtained from cardiologist.
Chest pain precautions provided to patient and family.
Course of Care: Female with worsening CHF exacerbation. Doubt ACS or PE given no chest pain and not tachycardic. Pt's CXR consistent with CHF and BNP elevated. Spoke with Dr. Thomas for Dr. Jones who agreed to admit pt to PCU. Pt given IV Lasix and diuresed over 1 liter, still slightly hypoxic when taken off O2 though, down to upper 80's. Pt appears stable for PCU admission though.
CONCLUSIONS: Changes suggest mild congestive failure. A comparison with prior films reveals that the findings are new.
Patient and family counseled in person many times regarding the patient's stable condition, test results, diagnosis and need for additional testing, admission and follow-up. Old ED and inpatient records reviewed.
Phone consult obtained from cardiology. Will see patient in the hospital today.
Disposition: Admitted to Progressive Care Unit. Condition: stable.
CLINICAL IMPRESSION
Dyspnea.
Acute moderate congestive heart failure.
John Kramer, MD
Electronically signed by JOHN KRAMER, MD 1/1/20XX
Why should the diabetes be reported as a diagnosis when it was only mentioned in the past history?