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CLINICAL EXAMPLE 99233
 

 

 


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A patient with worsening acute renal failure following CABG

CC : Follow-up ARF

Interval History: The patient’s ARF has worsened since yesterday and he has become oliguric.  Hypotension has resolved and in fact the patient is somewhat hypertensive today.  He is POD #4 from four vessel CABG.  Coronary disease has been stable with no evidence of ongoing ischemia.

Medications

Sliding scale insulin Coreg 12.5 PO BID , Lasix 40 mg PO QD , KCL prn, per protocol

ROS 

General--Positive for fatigue ; gative for fevers/chills
Cardiovascular—Positive for worsening edema; negative for chest pain, orthopnea or PND
GU-- Negative for flank pain, hematuria, dysuria, obstructive symptoms

Physical Exam

General: NAD, conversant, but somewhat anxious
Vitals: 160/90, 65, 98.6
HEENT: OP clear with MMM, No JVD
Lungs: CTA in front with faint bibasilar crackles in back
CV: RRR, with healing midline sternotomy
Extremities:  3+ bipedal edema; no digital cyanosis
Skin: Warm and dry with normal turgor; new rash or levido reticularis
Psyche: A&O times 3, with appropriate affect

Labs: BUN 67, creatinine 3.8, K 5.7, HCO3 18, HGB 9.0, BNP 1750

Assessment 

  1. Worsening oliguric ARF with hyperkalemia and metabolic acidosis
  2. Decompensated cardiomyopathy with evidence of CHF on exam
  3. Poorly controlled hypertension
  4. Worsening anemia
  5. CAD s/p CABG
Plan
  1. Stop oral furosemide
  2. Start bumex 2 mg IV Q6
  3. Chest X-ray in a.m.
  4. Recheck renal profile and CBC tomorrow
  5. Consider transfusion if HGB drops below 8.5
  6. No indication for dialysis today
  7. Patient and family updated at the bedside

For a detailed breakdown of this note with tips and advice see  99233 E/M Insight

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