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E/M Coding rounds: 12/17/2015
 

 

A hospital progress note...


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CC: Abdominal pain.

INTERVAL HISTORY: Patient continues to complain of severe abdominal pain.

EXAM: In moderate distress.  BP 144/84, HR 92, RR 22
RESPIRATORY: Lungs CTA.
CARDIOVASCULAR: Heart RRR.
GI: Abdomen is soft, tender to palpation.
PSYCH: Awake and alert.
NEURO: No tremors.

Labs: Na 137, K 4.2, Cl 101, CO2 31, BUN 31, creatinine 0.8, glucose 104, HGB 12, HCT 36, PLT 220.

IMPRESSION

  1. Worsening pancreatitis
  2. Stable diabetes
  3. Alcohol dependence, no evidence of active withdrawal

PLAN

  1. Continue NPO status.
  2. Continue IV fluids.
  3. Continue current insulin regimen.
  4. Continue CIWA protocol to monitor for withdrawal.
  5. Start IV Dilaudid, 1 mg Q 4H, PRN.

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