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CLINICAL EXAMPLE 99232
 

 

Hospital day #3 for a patient admitted with CHF exacerbation

CC: F/U CHF

Interval History : Patient states his shortness of breath has improved, but is still worsened when lying flat. 

ROS:  Cardiovascular--Negative for PND or chest pain

Physical Exam
General: NAD, conversant
Vitals: 150/74, 84, 24
Lungs: Bibasilar crackles
CV: RRR, with a soft systolic murmur
Abdomen: Soft, non-tender
Extremities: 2+ bipedal edema
Skin: Warm and dry; normal turgor

Labs: BUN 41, creatinine 1.4, K 3.3, HCO3 24

Assessment

  1. Sub-optimally controlled systolic CHF
  2. Worsening hypertension associated with volume overload
  3. Significant lower extremity edema
  4. Mild pre-renal azotemia associated with CHF
  5. Hypokalemia


Plan

  1. Increase furosemide from 40 mg PO QD to BID
  2. Increase KCL from 20 mEq PO QD to 30 mEq BID
  3. Give supplemental dose of 40 mEq KCL times one now
  4. Renal profile tomorrow
  5. Re-assess blood pressure control after resolution of hypervolemia

For a detailed breakdown of this note with tips and advice see  99232 E/M Insight

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