INDICATION: Surgical Clearance Chief complaint
HISTORY: Pt scheduled for left nephrectomy Location on 1/26/2010. Hx of HTN, non-insulin-dependent DM, CABG three times in 1995. Bladder tumor resection in 2002. Last month Duration kidney mass Quality was found. Denies hematuria, flank pain and fever Associated Signs and Symptoms. No chest pain on exertion. Activity limitied due to intermittent claudication. admists to dyspnea on mild exertion. has productive cough, clear mucous.
I got 4 elements as highligted above.
Laura, CPC, CPMA, CEMC
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