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CLINICAL EXAMPLE 99222
 

 
A patient with known COPD being admitted for shortness of breath

CC: “I can’t breath”

HPI :The patient is a 65 year old male with a history of COPD who thinks he may have “caught a cold” last week.  He has had worsening shortness of breath despite the use of inhalers at home.  He has a history of diabetes and hypertension, both of which have been well controlled.  Aside from his breathing difficulties, he has no spontaneous somatic complaints..

Medications
HCTZ 12.5 mg PO QD
Glyburide 5 mg PO BID
Albuteral/Atrovent MDIs
Atorvastatin 20 mg PO QD
Amlodipine 10 mp PO QD
Tylenol, prn

PMH: per HPI, plus a history of dyslipidemia

ROS    General - Positive for subjective fevers and chills; negative for fatigue, weight loss,
             Cardiovascular - Negative for chest pain, orthopnea or PND
             Pulmonary - Positive for non-productive cough; negative for hemoptysis

All other systems were reviewed and are negative.

FH: Father died at 75 of MI, mother at 81 of “old age”.  He has three grown sons all in good health. 

SH: Patient drinks approximately two cocktails per day and quit smoking five years ago after a 40 pack-year history.  He lives with his wife of 35 years in a trailer home.

Physical Exam

Vitals: 150/84, 28, 88, 98.6
General: In some respiratory distress; difficult to speak in full sentences, well nourished white male                       
Eyes: anicteric sclerae, moist conjunctiva; PERRLA
HENT: AT/NC; oropharynx clear with moist mucous membranes and no mucosal ulcerations; normal hard and soft palate Neck: Trachea midline; FROM, supple, no thyromegaly, lymphadenopathy
Lungs: CTA, with increased respiratory effort and postive intercostal retractions
CV: RRR, no MRGs; somewhat hyperdynamic PMI
Abdomen: Soft, non-tender; no masses or HSM, no abdominal or femoral bruits
Extremities: No peripheral edema or extremity lymphadenopathy
Skin: Normal temperature, turgor and texture; somewhat pallid complexion; no rash, ulcers or nodules; no levido reticularis
Psych: Appropriate affect, alert and oriented to person, place and time

Labs: Glucose 115, BUN 25, creatinine 1.4; Albumin 4.1, K 4.1, C02 33, HGB 14, WBC 11,000 CXR report was remarkable for hyperinflation; negative for infiltrate or effusions

Assessment
  1. Mild to moderate COPD exacerbation
  2. Stable Type 2 NIRDM
  3. Sub-optimally controlled hypertension
Plan
  1. Admit for intravenous steroids
  2. Nebulized bronchodilators
  3. Hold oral diabetic agents and cover with insulin sliding scale during steroid therapy
  4. Continue blood pressure medications for now and adjust as needed after resolution of respiratory distress

For a detailed breakdown of this note with tips and advice see   99222 E/M Insight

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