Hello,
I need help with practicode case. Did I do this correctly?
Thank you
Dx I chose: I51.89; Z86.79
CPT I chose: 99214-25; 93000
OFFICE - ESTABLISHED
SEX: Female AGE: 73
Date: 01/01/20XX
CHIEF COMPLAINT: She is here for echocardiogram results and surgery clearance.
PROBLEM LIST:
1. 73 y/o requesting surgery clearance for total knee.
2. History of unstable angina with stent to occluded circumflex marginal branch (20XX); recurrent left anterior chest pain occurring 1-3x/wk.
3. S/P left heart catheterization (20XX) showing patent circumflex stent with 60-70% native vessel stenosis immediately distal and right renal artery stenosis secondary to fibromuscular dysplasia, treated with angioplasty.
4. Hypertension (since 1998).
5. Hypercholesterolemia.
6. Positive family history for premature coronary disease.
7. Obstructive sleep apnea, on CPAP as Rx.
8. Excessive alcohol use, now 2-3 drinks a day since widowed (2012).
ALLERGIES: Codeine (syncope), Altace and other ACE inhibitor (tongue swelling)
MEDICATIONS:
Coreg 12.5 mg b.i.d.
Diovan 160 mg q.d.
Lipitor 80 mg q.d.
Aspirin 325 mg q.d.
Zetia 10 mg q.d.
Omeprazole 20 mg q.d.
Trilipix 135 mg q.i.d.
Tramadol 50 mg p.r.n. (not taking)
Multivitamin q.d.
Hydrocodone 1/2 tab a.m.
Celebrex 200 mg q.d.
Nitroglycerin sl p.r.n.
Xanax .25 mg q.d.
Escitalopram 12.5 mg q.d. (Lexapro)
Iron b.i.d.
INTERVAL HISTORY: Her alcohol has decreased to two to three drinks a day on weekends only, which is significantly improved from office visit six months ago. She is anticipating knee surgery in approximately 10 days.
Echocardiogram (01/01/20XX) shows:
1. Ejection fraction of 70-75%.
2. Mild hyperdynamic left ventricle.
3. Dilated left ventricle, left atrium and right ventricle.
EKG shows:
1. Sinus rhythm with occasional PVCs.
2. ST and T-wave abnormality but is no change from previous EKG. Her home blood pressures are 120/70.
PHYSICAL EXAMINATION:
VITAL SIGNS: Weight 195 lbs, BP 130/72 in the left arm, pulse 66 and regular, oxygen saturation 93% on room air.
CONSTITUTIONAL: Somewhat flat affect.
HEENT: Eyes: No xanthelasma or exophthalmos. No arcus senilis. Tongue midline. Mucous membranes moist, with no cyanosis.
RESPIRATORY: Respirations even and unlabored. Good air entry bilaterally. No adventitious sounds. Chest has normal contour.
CARDIOVASCULAR: PMI normal. Neck veins flat. No carotid bruits. S1, S2 and normal. S4 gallop. No murmur or clicks. Abdominal aorta not palpable, no bruit. Femoral, tibial, dorsalis pedis pulses intact. No leg swelling.
GASTROINTESTINAL: Abdomen: Soft. Positive BS x4 quads. No masses or tenderness. No hepatosplenomegaly.
SKIN: Pink, warm and dry. Skin intact. No rashes. No lesions. No clubbing or cyanosis.
MUSCULOSKELETAL: Gait is restricted due to lumbosacral and bilateral knee arthritis.
NEUROLOGIC/PSYCH: Cranial nerves II-XII grossly intact. Alert and oriented x3. Affect normal. Decreased sensation in her last three fingers of left hand.
ASSESSMENT:
1. Hyperkinetic left ventricular function.
2. History of mild bilateral carotid artery disease.
PLAN:
1. Increase Coreg to 25 mg b.i.d.
2. Office visit on Friday before surgery, to evaluate hyperdynamic left ventricle with limited echo just prior to monitor ejection fraction. If hyperdynamic left ventricle is improved, she will be at increased, but acceptable cardiac risk for knee surgery.
3. Carotid Doppler in early November, for ongoing monitoring of stenosis.
Robert Jones, MD
Electronically signed by ROBERT JONES, MD 1/1/20XX
I need help with practicode case. Did I do this correctly?
Thank you
Dx I chose: I51.89; Z86.79
CPT I chose: 99214-25; 93000
OFFICE - ESTABLISHED
SEX: Female AGE: 73
Date: 01/01/20XX
CHIEF COMPLAINT: She is here for echocardiogram results and surgery clearance.
PROBLEM LIST:
1. 73 y/o requesting surgery clearance for total knee.
2. History of unstable angina with stent to occluded circumflex marginal branch (20XX); recurrent left anterior chest pain occurring 1-3x/wk.
3. S/P left heart catheterization (20XX) showing patent circumflex stent with 60-70% native vessel stenosis immediately distal and right renal artery stenosis secondary to fibromuscular dysplasia, treated with angioplasty.
4. Hypertension (since 1998).
5. Hypercholesterolemia.
6. Positive family history for premature coronary disease.
7. Obstructive sleep apnea, on CPAP as Rx.
8. Excessive alcohol use, now 2-3 drinks a day since widowed (2012).
ALLERGIES: Codeine (syncope), Altace and other ACE inhibitor (tongue swelling)
MEDICATIONS:
Coreg 12.5 mg b.i.d.
Diovan 160 mg q.d.
Lipitor 80 mg q.d.
Aspirin 325 mg q.d.
Zetia 10 mg q.d.
Omeprazole 20 mg q.d.
Trilipix 135 mg q.i.d.
Tramadol 50 mg p.r.n. (not taking)
Multivitamin q.d.
Hydrocodone 1/2 tab a.m.
Celebrex 200 mg q.d.
Nitroglycerin sl p.r.n.
Xanax .25 mg q.d.
Escitalopram 12.5 mg q.d. (Lexapro)
Iron b.i.d.
INTERVAL HISTORY: Her alcohol has decreased to two to three drinks a day on weekends only, which is significantly improved from office visit six months ago. She is anticipating knee surgery in approximately 10 days.
Echocardiogram (01/01/20XX) shows:
1. Ejection fraction of 70-75%.
2. Mild hyperdynamic left ventricle.
3. Dilated left ventricle, left atrium and right ventricle.
EKG shows:
1. Sinus rhythm with occasional PVCs.
2. ST and T-wave abnormality but is no change from previous EKG. Her home blood pressures are 120/70.
PHYSICAL EXAMINATION:
VITAL SIGNS: Weight 195 lbs, BP 130/72 in the left arm, pulse 66 and regular, oxygen saturation 93% on room air.
CONSTITUTIONAL: Somewhat flat affect.
HEENT: Eyes: No xanthelasma or exophthalmos. No arcus senilis. Tongue midline. Mucous membranes moist, with no cyanosis.
RESPIRATORY: Respirations even and unlabored. Good air entry bilaterally. No adventitious sounds. Chest has normal contour.
CARDIOVASCULAR: PMI normal. Neck veins flat. No carotid bruits. S1, S2 and normal. S4 gallop. No murmur or clicks. Abdominal aorta not palpable, no bruit. Femoral, tibial, dorsalis pedis pulses intact. No leg swelling.
GASTROINTESTINAL: Abdomen: Soft. Positive BS x4 quads. No masses or tenderness. No hepatosplenomegaly.
SKIN: Pink, warm and dry. Skin intact. No rashes. No lesions. No clubbing or cyanosis.
MUSCULOSKELETAL: Gait is restricted due to lumbosacral and bilateral knee arthritis.
NEUROLOGIC/PSYCH: Cranial nerves II-XII grossly intact. Alert and oriented x3. Affect normal. Decreased sensation in her last three fingers of left hand.
ASSESSMENT:
1. Hyperkinetic left ventricular function.
2. History of mild bilateral carotid artery disease.
PLAN:
1. Increase Coreg to 25 mg b.i.d.
2. Office visit on Friday before surgery, to evaluate hyperdynamic left ventricle with limited echo just prior to monitor ejection fraction. If hyperdynamic left ventricle is improved, she will be at increased, but acceptable cardiac risk for knee surgery.
3. Carotid Doppler in early November, for ongoing monitoring of stenosis.
Robert Jones, MD
Electronically signed by ROBERT JONES, MD 1/1/20XX