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CLINICAL EXAMPLE 99245
 

 
65 Year old diabetic patient referred to cardiologist for possible CHF

Reason for consult : Evaluation and management of possible new onset CHF  

Requesting physician : John Doe, MD

HPI :The patient is a pleasant gentleman with a history of type 2 insulin requiring diabetes which was diagnoses approximately five years ago.  He states his glycemic control has been excellent on current therapy.  He also had a history of COPD which is usually stable on multiple inhalers, but he sometimes requires a short course of oral steroids.  He was diagnosed with hypertension over 20 years ago and reports that his blood pressure is usually well controlled on routine medications.  Recently, he has developed worsening shortness of breath in association with intermittent lower extremity edema and is referred today for evaluation of possible CHF.

Medications
Allopurinol 100 mg PO QD
Pravachol 40 mg PO QD
HCTZ 25 mg PO QD
NPH insulin 20 units SQ BID
Regular insulin sliding scale
Albuterol MDI, PRN
Atrovent MDI, PRN
Zantac, PRN

PMH : per HPI, plus a history of dyslipidemia, GERD and gout as well as a remote appendectomy 

ROS
General - Positive for occasional fatigue, negative for fevers or chills
Cardiovascular - Positive for two-pillow orthopnea, and fluctuating lower extremity edema, negative for chest pain
Pulmonary - Negative for cough, hemoptysis, or pleurisy
All other systems were reviewed and are negative.

FH : Father died at age 58 of an apparent MI.  Mother died of unknown type of cancer at age 78.  He has three brothers with no known history of heart disease and two grown daughters in good health.

SH : Patient quit smoking in 1988 after a 30 pack-year history; drinks two to three highballs per day. 
He lives in a condominium with his wife of 38 years.

Physical Exam

Vitals: 120/75, 68, 98.6 General appearance: NAD, conversant, well nourished white male with normal attention to grooming
Eyes: anicteric sclerae, moist conjunctiva with no lid-lag; PERRLA, fundi clear with sharp disc margins and normal posterior segments
HENT: AT/NC; oropharynx clear with moist mucous membranes; and normal dentition and gums
Neck: Trachea midline; FROM, supple, no lymphadenopathy, thyromegaly or carotid bruits; no JVD at 30 degrees
Lungs: CTA in front with bibasilar posterior crackles; normal respiratory effort; some dullness to percussion at left base
CV: RRR, no MRGs, normal PMI in the midclavicular line
Abdomen: Soft, non-tender; no masses or HSM, normal pulsatile abdominal aorta without bruits
Extremities: 2+ bipedal edema with brisk and symmetric pedal pulses; no extremity lymphadenopathy; no digital cyanosis or splinter hemorrhages
Skin: Normal temperature, turgor and texture; no rash, ulcers or nodules; no levido reticularis
Psych: Appropriate affect, alert and oriented to person, place and time

Labs: HGBA1c 7.0, BUN 14, creatinine 0.9, K 4.0, HGB 12.4, HCT 36, UA shows trace proteinuria
EKG was reviewed and showed LVH by voltage criteria with NSR and no diagnostic ST changes
Chest X-ray report from recent admission for COPD exacerbation was notable for moderate cardiomegaly

Assessment
  1. Possible new onset CHF with evidence of pulmonary vascular congestion and extracellular fluid volume excess on exam
  2. Well controlled diabetes
  3. Well controlled hypertension
  4. Trace proteinuria
Plan
  1. Will arrange for Echo and Nuclear stress test
  2. Renal profile, Lipid panel and spot protein/creatinine ratio on return
  3. Start furosemide 40 mg PO QD and KCL 20 mEq PO QD
  4. Patient was educated about a low sodium diet
  5. Will probably start ACE or ARB at next visit pending results of above
  6. Will send a copy of this note to Dr. Doe

For a detailed breakdown of this note with tips and advice see   99245 E/M Insight

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