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CLINICAL EXAMPLE 99223
 

 

68 Year old diabetic male with chest pain

CC: “Chest pain”

HPI : The patient is a 68 year old male who presents with chest pain which began approximately two hours ago.  The pain is described as “crushing” and 8/10 in severity.  He states the pain has been constant since onset and is sometimes associated with nausea and shortness of breath.  He has no known history of heart disease.  His pain improved following administration of i.v. morphine.

Medications
Glucotrol 10 mg PO QD
Pravachol 40 mg PO QD
Amlodipine 10 mg PO QD
Allopurinol 150 mg PO QD
Zantac, PRN

PMH : Hypertension, NIRDM, dyslipidemia, GERD and gout as well as a remote tonsillectomy over 25 years ago; no known drug allergies

ROS     General - Positive for occasional fatigue, negative for fevers or chills                        
             Cardiovascular - per HPI, plus intermittent lower extremity edema; no orthopnea or PND                        
             Pulmonary - Negative for cough, hemoptysis, or pleuritic chest pain

   All other systems were reviewed and are negative.

FH : Father died at age 48 of an acute MI.  Mother is alive in her 90s and has Alzheimer’s disease; he has no siblings and one grown son in good health.

SH : Patient quit smoking in 1978 after a 15 pack-year history; drinks two to three martinis per day.  He lives in single family home with his wife of 35 years.

Physical Exam

Vitals: 180/75, 108, 98.6
General appearance: Anxious and agitated well nourished white male who looks stated age
Eyes: anicteric sclerae, moist conjunctiva with no lid-lag; PERRLA
HENT: AT/NC; oropharynx clear with moist mucous membranes and normal hard/soft palate
Neck: Trachea midline; FROM, supple, thyromegaly or carotid bruits; no JVD at 30 degrees
Lungs: CTA in front with bibasilar posterior crackles worse on the left; normal respiratory effort
CV: RRR, no MRGs, hyperdynamic PMI in the midclavicular line
Abdomen: Soft, non-tender; no masses or HSM, normal pulsatile abdominal aorta without bruits
Extremities: 1+ bipedal edema with symmetrically diminished pedal pulses; no digital cyanosis or splinter hemorrhages
Skin: Normal temperature, turgor and texture; no rash, ulcers or nodules; no levido reticularis
Neurologic: Cranial nerves II-XII grossly intact; symmetrically decreased light touch sensation in both lower extremities
Psych: Appropriate affect, alert and oriented to person, place and time

Labs: Glucose 115, BUN 14, creatinine 0.9, K 4.0, HGB 12.4, HCT 36, troponins are pending
CXR was reviewed and showed no infiltrate or effusions; normal heart size
EKG was reviewed and showed LVH by voltage criteria with NSR and no diagnostic ST changes

Assessment

  1. Chest pain with high suspicion for unstable angina or acute MI
  2. Sub-optimally controlled hypertension
  3. Stable diabetes
  4. History of dyslipidemia
Plan
  1. Follow results of cardiac enzymes ASAP
  2. Admit to CCU with i.v. morphine as needed for pain
  3. ASA
  4. Intravenous metoprolol
  5. NTG drip
  6. Heparin drip per protocol
  7. Echocardiogram today
  8. Sliding scale insulin
  9. Monitor and control hypertension
  10. Lipid panel prior to discharge

For a detailed breakdown of this note with tips and advice see   99223 E/M Insight

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