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CLINICAL EXAMPLE
(2) 99233 |
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A patient with worsening CHF
CC : Follow-up CHF exacerbation
Interval History: The patient’s CHF symptoms have worsened most likely due to dietary noncompliance leading to increased salt intake. HTN is poorly controlled as well due to hypervolemia. Hypokalemia has stabilized following initiation of potassium repletion protocol .
Medications
Coreg 12.5 PO BID
Lasix 40 mg PO QD
KCL prn, per protocol
ROS : General--Positive for fatigue; negative for fevers/chills
Cardiovascular—Positive for worsening edema; negative for chest pain, orthopnea or PND
Pulm-- Positive for DOE; negative for SOBAR or cough
Physical Exam
General: NAD, some dyspnea at rest
Vitals: 160/90, 65, 98.6
HEENT: Positive JVD
Lungs: Bibasilar crackles
CV: RRR, no MRGs
Extremities: 3+ bipedal edema; no digital cyanosis
Psyche: A&O times 3, with appropriate affect
Labs: BUN 33, creatinine 1.6, K 4.0, HCO3 20, HGB 11.0, BNP 1750
CXR was reviewed and showed increased pulmonary vascular congestion and a small left effusion
Assessment
- Decompensated cardiomyopathy with acute exacerbation of CHF
- Poorly controlled hypertension due to fluid overload
- Resolving hypokalemia
Plan
- Stop oral furosemide
- Start bumex 2 mg IV BID and continue potassium repletion protocol
- Repeat chest X-ray in a.m.
- Recheck renal profile and CBC tomorrow
- Repeat BNP in a.m.
For a detailed breakdown of this note with tips and advice see 99233 (2) E/M Insight
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