A hospital progress note...
Click the video to get the answer.
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.
- Worsening pancreatitis
- Stable diabetes
- Alcohol dependence, no evidence of active withdrawal
- Continue NPO status.
- Continue IV fluids.
- Continue current insulin regimen.
- Continue CIWA protocol to monitor for withdrawal.
- Start IV Dilaudid, 1 mg Q 4H, PRN.
View comments. Post a comment. Join the discussion.
The Free E/M Coding Curriculum
The free basic course, coding guide and templates
The Complete E/M Coding Curriculum
Get instant access to all web-based E/M coding courses for CME credit
The Hospitalist E/M Coding Curriculum
E/M coding courses designed for hospitalists
The Outpatient E/M Coding Curriculum
E/M coding courses for outpatient encounters
The Pediatric E/M Coding Curriculum
E/M coding courses designed for pediatricians
E/M Compliance Web Portals
A centralized platform for E/M coding education for multiple providers