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CLINICAL EXAMPLE 99253
 

 

A patient with diabetes about to undergo knee replacement

Reason for consult : Uncontrolled diabetes

Requesting physician : John Doe, MD

HPI : The patient is a 52 year old male being admitted for right knee replacement surgery planned for tomorrow.  The patient has a history of osteoarthritis and underwent similar surgery on his left knee earlier this year.  He also has well controlled diabetes for which he has been taking oral medications for about six years and “borderline” high blood pressure, which he says has never required medication.  He has no spontaneous somatic complaints.

Medications
Metformin 1000 mg PO BID
Actos 30 mg PO QD

PFSH is notable for significant alcohol consumption of approximately five to six drinks per day

ROS
Musculoskeletal - Positive per HPI, plus occasional shoulder pain on the right, negative for myalgias or joint swelling
Endocrine - Negative for polyuria, polydipsia, or previous episodes of symptomatic hypoglycemia
GI - Negative for PUD, gastritis, GERD or previous episodes of GI bleeding

Physical Exam

General: NAD, conversant and well developed white male with normal attention to grooming
Vitals: 130/80, 72, 98.6
Neck: Supple, FROM; no thyromegaly or carotid bruits
Lungs: CTA bilaterally
CV: RRR, no MRGs
Abdomen: Soft, non-tender with no HSM; normal aortic size and pulsations
Extremities: No peripheral edema or digital cyanosis; pedal pulses are intact and brisk bilaterally

Labs: Glucose 221, BUN 10 creatinine 0.8, K 4.2, HGB 12.2

Assessment

  1. Sub-optimally controlled DM2
  2. History of significant long-term alcohol consumption

Plan

  1. Discontinue oral diabetic medications
  2. Accu checks QAC an HS
  3. Sliding scale insulin
  4. PPI for ulcer prophylaxis
  5. Monitor electrolytes carefully post-op
  6. Monitor for Etoh withdrawal
  7. Routine anticoagulation

For a detailed breakdown of this note with tips and advice see  99253 E/M Insight

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