E/M Coding Rounds Case of the Week: 9/03/08

This is what happened....

I saw one of my patients in the hospital who was being treated for CHF. He had worsening kidney function and I thought we had over-diuresed him. I stopped his diuretics and started him on IV fluids. I documented a level three hospital progress note (99233) at 08:30.

Then...the following note was documented:

CTSP stat for acute SOB

Ealier today, diuretics were discontinued due to worsening azotemia. The patient was started on conservative volume expansion with isotonic saline. Two hours later he developed chest pain and severe hypotension. Exam showed severe bibasilar crackes more than half way up. Troponin was 2.3. EKG showed ST depression in the lateral leads and peaked T waves diffusely. Stat chem 7 showed a creatinine of 3.2 and a potassium of 6.6. We gave one dose of kayexalate on the floor along with two grams of calcium gluconate and transferred the patient to the ICU.

Impression:

1. Acute MI with cardiogenic shock
2. ARF
3. Severe hyperkalemia
4. Underlying ischemic cardiomyopathy

Plan:

1. Start heparin
2. 10 units Regular insulin
3. Two amps of bicarb
4. Repeat chem 7
5. Consult cardiology
6. Consult nephrology

Total critical care time on the floor and in the ICU: 45 minutes.