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Help me choose LOS..est patient

  1. #1
    Default Help me choose LOS..est patient
    Medical Coding Books
    Patient is a 69-year-old female in today for a number of issues.

    1. Diabetes. Her hemoglobin A1c last checked on November 27, 2007, was 7.4.
    She denies any diabetic symptoms. She brings her blood sugar book in and she
    is checking it once a day, or her daughter is, and it actually looks good for
    the most part. She is taking Glipizide 10 mg twice daily, Metformin 1 gram
    twice daily as well as Avandia 4 mg twice daily. She has had no major
    complaints with regards to peripheral neurovascular complaints. She is
    significantly and morbidly obese. She has not been moving at all. She keeps
    blaming her legs for pain and low back pain for not moving, but she has not
    done anything at all even while living with her daughter. She does need an
    eye check. Her daughter is going to schedule her for this.

    2. Hyperlipidemia. Her triglycerides, last checked on November 21, 2007,
    were 163, HDL was 59, LDL was 64. She is taking the Avandia as above as well
    as Lipitor 20 mg p.o. daily. She has no complaints with this medication.
    She does not think it is causing any major problems.

    3. Hypertension. The blood pressures today are 146/74 on right and 146/78
    on the left. She also brought her blood pressures from home with a
    calibrated cuff. These are too high. They are in the 140s to 150s as well.
    No complaints with regards to palpitations, syncopal episodes, DOE, PND, or
    orthopnea. No chest pain with cold air exposure or exertion. No RF, SF. No
    valvular problems. She has no other new complaints with cardiopulmonary set
    review of systems but she does not do anything so she does not have any

    Heart disease in her father with enlarged heart and she has a son with
    significant hypertrophic cardiomyopathy. A sister with severe venous
    insufficiency and diabetes who recently died from what appeared to be
    metastatic breast cancer. The same sister had peripheral vascular disease
    and hypertension.

    No AODA. No tobacco. She is widowed. She has been living with her
    daughter, Kaye since last October. Does not really do anything, she does
    love to cook and unfortunately she is doing that.

    As above,
    1. Glipizide 10 mg twice daily.
    2. Metformin 1 gram twice daily.
    3. ASA 1 daily.
    4. Amlodipine 10 mg daily.
    5. Avandia 4 mg twice daily.
    6. Lasix 40 mg daily.
    7. Enalapril 20 mg twice daily.
    8. Lipitor 20 mg daily.
    9. Toprol XL 100 mg p.o. daily.
    10. Accu-Chek daily.

    She has no allergies.

    GENERAL: Please see above. Exceedingly sedentary. She does not seem to
    have a problem with doing this except her daughter states she whines about it
    all the time. No night sweats, chills, or fevers. She states she is not
    eating much. Her weight is 21 lbs. heavier than it was last November.

    ENDO/THYROID: Please see above. She denies any thyroid review of systems.
    No heat or cold intolerance. No constipation or significant diarrhea. No
    abnormal diaphoresis or palpitations. No tachycardia. No skin pigmentation
    changes. No hair, skin or nail changes. No problems with polyuria,
    polydipsia, or polyphagia. No diaphoresis, or headaches associated with
    flushing of the skin.

    HEENT: Needs the eyes checked. No complaints with regards to epistaxis,
    rhinitis or sinusitis. No sensorineural loss. No cervical or cephalic

    PULM: Please see above. Denies any cold air exposure causing shortness of
    breath. No hemoptysis, TB, chronic or recurrent pneumonitis/bronchitis. No
    nocturnal or early morning cough.

    CV: See above

    GI: Colonoscopy. She has had a history of colonoscopy years ago. It sounds
    like she was awake so I am thinking it was a flex sig. No complaints with
    regards to hematemesis, melena, hematochezia. No GERD or PUD complaints. No
    hepatitis, pancreatitis or jaundice. No complaints with regards to renal
    lithiasis or pyelonephritis. No complaints with regards to easy bruising or
    bleeding. No change in color, caliber or character of stools.

    GU: She has not had a Pap and pelvic for years. She denies any
    postmenopausal bleeding. She does have problems with regards to bladder
    control. Sometimes she thinks it is because she cannot make it to the
    bathroom fast enough. She is a G10, P10-0-1-9 female. She had SVDs. She
    denies any problems with regards to abnormal pelvic bloating but once again
    she is so obese who could tell. She has problems, once again, with urinary
    incontinence because of inability to get up and move to the bathroom quick
    enough. She denies any hematuria or dysuria. There has been no notable
    pyuria. She does sometimes smell of urine. She states she thinks she is
    doing better now than she has for some time.

    MS: She has a right TKA. She does not want to have any more arthroplasties
    done. This one failed because she did not move. She has no radicular
    symptoms. Please see below.

    NEURO: Please see above. No lumbar or cervical radicular complaints. No
    history of depression, schizophrenia or affective disorder. No history of

    HEME: Please see above. No history of petechiae, purpura or ecchymosis. No
    problems with poor wound healing. No night sweats, chills or fevers. No
    peripheral adenopathy.

    INTEGUMENT: Relatively benign.

    O: As above. Blood pressure: 146/74 right, 146/78 left. Pulse: 72.
    Temperature: 97.2. Could not get the height because she is too unsteady.
    Weight: 327 lbs.

    GENERAL: Morbidly obese female and actually a fairly bright affect.

    SKIN: Actually fairly clear for the most part. No ulcerations or sores.
    She has no ulcerations or sores on the feet, a little tinea pedis present but
    not bad. Her left great toenail is extremely long and thickened.

    HEENT: Auricles, canals and TMs are clear. Eyes show bilateral arcus
    senilis. Sclerae are clear. PERRLA. EOMI. Nares are mildly erythematous.
    She has reduced number of teeth with no dentures. Normal mucosa. Neck is
    without masses, adenopathy or palpable thyromegaly. No JVD or bruits.

    CHEST: Obese, lungs are clear without rhonchi, wheezes or rales.
    HEART: RRR without murmurs or gallops. No lifts or heaves noted.

    BREAST: No palpable or visual masses. No supraclavicular axillary
    tenderness. No skin dimpling or nipple retraction.

    ABDOMEN: Morbidly obese. Benign. No apparent mass, HSM. No tenderness or
    guarding. Normal bowel sounds throughout. No evidence of ventral herniation.

    BACK: No CVAT. No palpable or visual deformities.

    GU: Deferred by patient.

    EXTREMITIES: She actually has good dorsalis pedis pulses in the feet. There
    are no ulcerations or sores noted on the feet. They are very puffy, but this
    is from edema. She has no ulcerations or sores on the ankles. Upper
    extremities look good, no joint erythema or edema noted here.

    NEURO: Normal monofilament testing in the feet bilaterally. Trace response
    to DTRs in the upper and lower extremities and symmetric bilaterally.

    1. Diabetes. Not in that good of control at all. I need to see more
    sugars. I have her pretty much maxed out on oral therapy. I am worried
    about this. She may need to go on insulin. We will see what the next
    hemoglobin A1c shows.

    2. Hypertension not adequately controlled. I am going to swap out her
    Toprol for Coreg.

    3. Morbid obesity. She will not do anything about this.

    4. Incontinence. Question real etiology here. I think it is just because
    she cannot get moving and does not get to the bathroom in time.

    5. OA (osteoarthritis). She actually probably could use a left TKA, but she
    will not get that done either because she failed the first one because she
    did not move.

    6. She needs a colonoscopy. She also needs a mammogram. I would like to
    also get her eyes checked.

    1. Stop the Toprol and start on Coreg 3.125 1/2 p.o. twice daily. This will
    be sent to her. Daughter knows about it and she will make sure it happens.
    We will just keep an eye on the blood pressures. I want her at 125/75.

    2. FLP, ALT, hemoglobin A1c, BMP, and a 24-hour UA.

    3. She needs a colonoscopy. We will call and set this up with GI, and her
    daughter is aware of this.

    4. I implored her to get moving. I do not think she is gonna. This is a
    bad situation and it is getting worse.

    5. We will follow from here.

  2. Default
    Jagadish, CCS-P, CPC

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