'Click to return to E/M University Home page, EM Coding Education
99291 EXAMPLE
 

 
A patient with ATN in the setting of multisystem organ failure

CC: Follow-up ARF

Interval history: The patient remains intubated in the ICU.  He is hemodynamically unstable, requiring dopamine to maintain systolic pressures in the 90s.  Urine output was 250 cc over the past 24 hours.  Tolerating tube feeds at 30 cc/hr.

Exam

BP 94/60, 92, 97.1
H/N: MMM no JVD
Lungs: coarse anterior rhonchi and lateral crackles
CV: RRR no rub
Abd: soft with positive bowel sounds
Ext: 2+ peripheral edema
Skin: warm and dry; well perfused
Labs: BUN 99, creatinine 2.9, K 3.8, CO2 18, HGB 8.9; PLTS 157; ABG  pH 7.28/46/78
CXR shows bilateral pleural effusions and mild pulmonary vascular congestion

Assessment

  1. Oligoanuric ATN
  2. Mixed acidosis
  3. Hypervolemia
  4. Hypoxemic respiratory failure

Plan

  1. Bumex 2 mg iv q6
  2. Titrate dopamine to maintain SBP > 90 mmHG
  3. Transfuse 2 units PRBCs
  4. Repeat CXR, renal profile and CBC in a.m.
  5. Family updated at the bedside
  6. 37 minutes of critical care time provided
For a detailed breakdown of this note with tips and advice see  99291 E/M Insight
Home   |   Contact Us   |   Privacy Policy
Copyright © 2003 -  EM University. Web Design: Abacus Web Services
 
Click to return to E/M University Home page, EM Coding Education