E/M Coding Rounds Case of the Week: 6/25/08

An Admission H&P

What level of care is documented?

CC:  Chest pain.

HPI:  The patient complains of intermittent, exertional sub-sternal chest pain associated with shortness of breath.

FH: Remarkable for acute MI in father at age 56

SH: Smokes 2 PPD

Allergies: Keflex

REVIEW OF SYSTEMS

Cardiovascular: Per HPI; Negative for orthopnea of edema

Pulmonary: Negative for cough or hemoptysis

GI: Negative for N/V/D

All other systems reviewed and are negative.

PHYSICAL EXAMINATION:  GENERAL: He is awake and alert and in NAD. Vitals: BP 151/79, HR 85, RR 20. EYES: Pink conjunctivae; no lid lag; PERRLA. ENMT: No rhinophyma or earlobe creases; PERRLA. NECK: FROM; supple; No JVD or thryrogemaly. LUNGS: Clear bilaterally, with normal respiratory effort. CV: Regular rate and rhythm; no MRGs. ABD: Soft, non-tender; no HSM. EXTREMITIES: No peripheral edema. SKIN: Warm and dry; well perfused; no rash or ulcers. PSYCH: Agitated affect; A&OX4


LABORATORY INFORMATION:  Trop 0.05, BUN 18, creatinine 0.7, Potassium 4.1, HGB 14.1

EKG: Reviewed. Shows NSR without diagnostic ST changes.

CXR: Reported as NAD.


IMPRESSION:

1. Chest pain consistent with USA.
2. HTN.

PLAN:

1. ASA given in ER
2. LMW
3. Metoprolol 25 mg PO BID
4. NTP 1" Q 6H
5. Follow cardiac enzymes per protocol
6. Consider stress echo in a.m.