Reference no: EM133201820

CPT and ICD code for the following case:

CASE 1-5A
Initial Hospital Care

The patient in Case 1-5 is an 87-year-old female who is to be admitted by her nephrologist, Dr. Pleasant, after the patient had been seen in Dr. Pleasant's office that morning. The physician also went to the emergency department to care for the patient.

LOCATION: Inpatient, Hospital

PATIENT: Rosie Hovett

ATTENDING PHYSICIAN: Timothy L. Pleasant, MD

I am admitting this patient primarily because of symptomatic bradycardia secondary to medications. The patient is an 87-year-old woman who was recently discharged from the hospital after being diagnosed with new-onset atrial fibrillation with rapid ventricular response. The patient was started on medications digoxin, labetalol, Cardizem, and metoprolol.

Since discharge from the hospital back on May 20, the patient has related that she has had some episodes of weakness. There were also some episodes when she was noted to be significantly hypotensive and feeling generally weak with some diaphoresis. Because these symptoms persisted, the patient then decided to come into the emergency room, where she was found to be in bradycardia, with a heart rate in the 40s to 50s. I think this is primarily brought about by the combination of digoxin, labetalol, Cardizem, and metoprolol. Therefore, at this time, the plan is to admit the patient to the telemetry unit and rule her out for MI (myocardial infarction) because she is also at risk for that problem. At this time, I am going to hold the digoxin, labetalol, Cardizem, and metoprolol. Obviously we cannot hold the clonidine patch because this may lead to rebound hypertension. I will continue the rest of her medications except for the ones that I have mentioned above.

We will also check her cardiac enzymes to rule out MI.

The patient has a past medical and past surgical history that consists of the following:

1. Hypertension.
2. New-onset atrial fibrillation.
3. Thoracic abdominal aortic aneurysm.
4. Hyperthyroidism. I am not exactly sure which one she has-hyperthyroidism or hypothyroidism-because the discharge summary indicates the presence of hypothyroidism, whereas the admission history and physical per Dr. Green indicated hyperthyroidism. Nevertheless, she is not on any thyroid supplements. If she indeed is hypothyroid, this certainly could contribute to her present situation as well. We need to review her old medical records for this particular issue.
SOCIAL HISTORY: The patient is currently retired. She does have family here in town. She is widowed and lives on her own. She has an 86-pack-a-year smoking history. She denies any current or previous use of alcohol or intravenous or recreational drugs.

FAMILY HISTORY is positive for cancer and diabetes and negative for heart disease, hypertension, stroke, kidney disease, bleeding disorder, or dyscrasia. A sister has been diagnosed with breast cancer, and her two other sisters have been diagnosed with uterine cancer. There is a strong family history of diabetes in the immediate family.

MEDICATIONS currently being taken at home include the following:

1. Clonidine patch.
2. Digoxin 0.125 mg (milligram) q.d. (every day).
3. Diltiazem CD 240 mg q.d.
4. Vasotec 10 mg q.d.
5. Labetalol 200 mg b.i.d. (twice a day).
6. Maalox extra strength 15 ml (milliliter) q.h.s. (each bedtime).
7. Metoprolol 25 mg q.h.s.
8. Nitroglycerin sublingual 0.4 mg p.r.n. (as needed).
ALLERGIES: No known drug allergies.

Latest laboratory results are as follows: Hemogram shows an H&H (hematocrit and hemoglobin) of 10.6/31.4, WBC (white blood count) 7.5, normochromic/normocytic indices, platelets 182. There is no left shift as neutrophils are only 63.6%. Chemistries are as follows: sodium 141, potassium 4.3, chloride 105, CO2 (carbon dioxide) 27.2, BUN (blood urea nitrogen) and creatinine 19.1/1, glucose 146, calcium 9.1. Digoxin level is 0.3, which is low. Magnesium level is 1.6. Cardiac enzymes are essentially unremarkable, as troponin is less than 0.3 and CK-MB (creatine kinase-methylene blue) is less than 1 and total CPK (creatine phosphokinase) is 36. Thyroid function tests done on previous admission were well within normal limits, as TSH (thyroid stimulating hormone) was measured to be 4.53.

REVIEW OF SYSTEMS: Constitutional: No fever or chills. No recent weight change. She appears to be fairly weak. No night sweats. Skin: No skin lesions. No active dermatosis. Eyes: No eye discharge. No eye itching. No visual changes. No diplopia. ENT: No ear discharge. No hearing difficulty. No pharyngeal hyperemia, congestion, or exudates. Lymph nodes: No lymphadenopathy in the neck, axillary, or groin. Neurologic: Positive headaches. Positive gait instability. No falls. No seizures. Psychiatric: No behavioral changes. Neck: No thyromegaly. Respiratory: Positive cough. No colds. No hemoptysis. Positive for shortness of breath with strenuous exertion only. No colds. No hemoptysis. Cardiovascular: No chest pain. Positive palpitations. No orthopnea. No paroxysmal nocturnal dyspnea. Gastrointestinal: Positive anorexia. No nausea, vomiting, dysphagia, odynophagia, constipation, or diarrhea. No abdominal pain. No fecal incontinence. No hematemesis. No hematochezia. No melena. Genitourinary: No urgency, frequency, dysuria, hematuria, urinary incontinence, nocturia, vaginal discharge, vaginal lesions, or vaginal bleeding. Musculoskeletal: Positive joint pains. Positive occasional muscle pains/weaknesses. Hematologic: No bleeding tendencies. No purpura. No petechiae. No ecchymosis. Endocrinologic: No heat or cold intolerance.

PHYSICAL EXAMINATION: Vital signs are stable. Blood pressure is 117/80. Heart rate is in the 50s. Respirations 20. She is afebrile. Normocephalic, atraumatic. Pink palpebral conjunctivae, anicteric sclerae. No nasal or aural discharge. Moist tongue and buccal mucosa. No pharyngeal hyperemia, congestion, or exudate. Supple neck. No lymphadenopathy. Symmetrical chest expansion. No retractions. Positive rhonchi. A few bibasilar crackles. No wheezes. S1 (first heart sound) and S2 (second heart sound) are distinct. No S3 (third heart sound) or S4 (fourth heart sound). Regular rate and rhythm. Abdomen: Positive bowel sounds. Soft, nontender. Both upper and lower extremities reveal arthritic changes. Pulses are fair.

ASSESSMENT/PLAN:

1. Symptomatic bradycardia secondary to medications, namely, digoxin, labetalol, Cardizem, and metoprolol. Admit to telemetry. Check cardiac enzymes to rule out MI. Start enteric-coated aspirin 325 mg q.d.

Please note this patient also had a recent 2-D echocardiogram performed by Dr. Monson showing a normal overall LV (left ventricle) systolic function, 3+ mitral insufficiency, 1-2+ aortic insufficiency, 2-3+ tricuspid insufficiency, 1+ pulmonic valve insufficiency, and moderate pulmonary hypertension.

2. Anemia, questionable etiology. Would need to review old medical records to see whether this has been worked up already. Anemia in this elderly age group needs to be evaluated more closely because the possibility of malignancy runs high on the list.

3. History of hypothyroidism, stable. She is not requiring thyroid supplements. As noted above, the latest TSH (thyroid stimulating hormone) level was well within normal limits.

4. Thoracic abdominal aortic aneurysm, stable.

5. Hypertension. Blood pressure right now is well controlled with a systolic blood pressure ranging from 117 to 120. There may be a possibility of her blood pressure going up because we are withholding three of her blood pressure medications, namely, labetalol, Cardizem, and metoprolol. At this time, we just have to continue to observe the patient, and if blood pressure goes up to higher levels, then we may consider starting the patient on either labetalol or Norvasc.

6. Atrial fibrillation. I am wondering why this patient was not placed on anticoagulation. We will check PT (prothrombin time) and INR (International Normalized Ration). We will discuss with Dr. Green on Monday whether or not the patient needs to be anticoagulated or whether there is a contraindication that was noted in the past. Unit time was 2 hours and 20 minutes. We will continue to follow up on this patient from the critical care standpoint.