CASE 9-2A Admission History and Physical (Physician’s and Resident’s Notes) Dr. Dawson admitted Mr.

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CASE 9-2A
Admission History and Physical (Physician’s and Resident’s Notes)

Dr. Dawson admitted Mr. Gulman to the hospital and prepared an admission history and physical. Dr. Grovedahl is a resident being supervised by Dr. Dawson. When completing the audit form for the admission service, place a “✓” on the form to indicate elements Dr. Dawson provided and an “×” to indicate elements Dr. Grovedahl provided. Dr. Grovedahl performed only part of the service because Dr. Dawson also contributed to the service. Assume that the third-party payer requires the use of the HCPCS modifiers for those services provided in part by a resident.

LOCATION: Inpatient, Hospital

PATIENT: Ervin Gulman

PRIMARY CARE PHYSICIAN: Ronald Green, MD

ATTENDING PHYSICIAN: Gregory Dawson, MD

PHYSICIAN ADMISSION NOTES: The emergency room notified that the patient presented himself there with increasing shortness of breath, and of course he had an abnormal chest x-ray. This is the same patient I tried to talk into coming into the emergency room earlier, and Dr. Green also tried even a week before that, and he has now agreed that perhaps he is sick enough to come in.

He is a patient who is well known to me, so a lot of history is already in the clinic chart. His past medical history, social history, family history, and review of systems are outlined in detail by my resident. Please see the resident’s note for complete details of the entrance history and physical.

The patient has significant COPD (chronic obstructive pulmonary disease) with hypoxic, hypercarbic respiratory failure on today’s blood gases. He has had diminished appetite for a couple of weeks and dry mouth, and he is too short of breath really to eat well. He is on home O2 (report dependence on supplemental oxygen with a V code), and he has been on Avalax since the 10th. Before that he had a week’s worth of antibiotics as well, but I do not know what they were. No fevers, sweats, or chills were present. He had increasing malaise, and he had some fever, with a temperature of 101° F to 102° F before admission.

The time I saw the patient revealed a very ill-appearing white male. HEENT (head, ears, eyes, nose, throat) is benign. No blood in the nose or posterior pharynx. The neck is supple without adenopathy. No JVD (jugular vein distention). Thyroid is not palpably enlarged. Lungs have diminished air movement everywhere, with rales in the right. No wheezes, rhonchi, or rubs. Heart shows a heart rate of about 110. I thought it was regular, without an S3 (third heart sound) or S4 (fourth heart sound). No diastolic sounds, clicks, or rubs; maybe a grade 1 murmur over the fourth intercostal, but his heart is so fast I am not sure what exactly I am hearing at this point. Abdomen is benign without hepatosplenomegaly. Normal bowel sounds are present. No bruits are heard in either flank. No masses are palpable, nontender, somewhat distended and tympanitis but within the range of normal. Neurologically he is awake and alert. Extremities show no edema, rashes, clubbing, cyanosis, or tremor except some ecchymosis in his upper arms, probably from steroid use. Neurologic: Cranial nerves II-XII are intact, and there is symmetrical strength in all four extremities. A detailed exam is not done because of his respiratory distress. Lymphatics: There are no nodes in the neck, clavicular, or axillary area.

IMPRESSION:

1. Acute pneumonia, organism unknown with secondary acute bronchospasm superimposed in a patient with significant COPD and respiratory failure. He will be admitted for antibiotic use and bronchodilator therapy, and we will have to look more into this hypercarbia. If the problem gets too great, we might have difficulty because this patient did not tolerate the BiPAP mask because of claustrophobia.
2. Chronic anxiety: In fact, that is why he is on BuSpar. We will try to get into him as soon as we can, but I do not really want to do it right today because of the elevated pCO2 (partial pressure of carbon dioxide) (not reported).

CPT: 

ICD 10: 

LOCATION: Inpatient, Hospital

PATIENT: Ervin Gulman

PRIMARY CARE PHYSICIAN: Ronald Green, MD

ATTENDING PHYSICIAN: Gregory Dawson, MD

RESIDENT: Mandy Grovedahl, MD

CHIEF COMPLAINT: Increasing shortness of breath and malaise

HISTORY OF PRESENT ILLNESS: This 73-year-old male was seen in Dr. Green’s office 1 week ago to follow up on pneumonia. The patient had been taking quinolone for a week for a pneumonia that had been diagnosed approximately 2 weeks previously when he had presented with cough, fever, chills, and shortness of breath. Since then, those symptoms have resolved. The patient complained of a decreased appetite at home and complaining of a dry mouth. He is on home O2 and has been on Avelox since the 10th when he went to the office to see Dr. Green. Over the past 2 days he has complained of increasing shortness of breath, increasing malaise, temperature 101° F to 102° F yesterday. He denies any nausea, vomiting, or diarrhea.

PAST MEDICAL HISTORY:

1. Severe chronic obstructive pulmonary disease
2. Congestive heart failure
3. Elevated PSA (prostate specific antigen) in the past
MEDICATIONS:

1. BuSpar 10 mg (milligram) b.i.d. (twice a day).
2. Lasix 40 mg q.d. (every day).
3. Ibuprofen 1 tab p.r.n. (as needed).
4. Albuterol 0.5% nebulizer q.6h. (every 6 hours).
5. AeroBid inhalers 4 puffs b.i.d.
6. Albuterol sulfate 0.5 mg with each nebulizer treatment.
7. Serevent 2 puffs q.12h.
8. Atrovent 2 puffs q.i.d. (four times a day).
ALLERGIES: Aspirin

PAST SURGICAL HISTORY: Right jaw repair following a broken jaw. No other surgeries.

FAMILY HISTORY: Father passed away at age 86 of congestive heart failure. Mother passed away at age 78 of colon cancer. The patient has three brothers and one sister alive. Two brothers have pacemakers. One sister has COPD.

SOCIAL HISTORY: Patient one pack daily × 45-year smoker. He quit approximately 15 years ago. He does have a history of heavy drinking in the past but denies any current use. He currently lives in Manytown with his wife.

REVIEW OF SYSTEMS: Constitutional: The patient indicates that there was an 18-pound weight loss approximately 2 months ago secondary to some fluid overload. He denies any headaches. He has had a decreased appetite in the past week or so, and he sleeps well with no problems. Eyes: Denies any history of glaucoma and has no eye pain or blurry or double vision. Ears, nose, mouth, and throat: No hearing problems reported. No bleeding from the nose or mouth. Cardiovascular: Denies palpitations. Denies any pressure or racing heartbeat. He does complain of some substernal chest pain off and on with exertion, last experienced approximately 1 week ago. Respiratory: Chronic cough, which is productive of white sputum. Dyspnea on exertion. GI (gastrointestinal): No history of ulcers. No digestive problems. He has had some positive stools recently. GU (genitourinary): History of prostate problems. Positive burning with urination recently. Skin: Complaint of dryness around the nares. No rashes. No nonhealing lesions. Musculoskeletal: No arthritis. No complaints of joint pain. No loss of muscle strength. Psych: Patient does have a history of anxiety secondary to shortness of breath. Neuro: No epilepsy or history of seizures. Hematology: Patient states he bruises easily. He does not have a bleeding problem. Endocrine: No kidney problems. No thyroid problems.

PHYSICAL EXAMINATION: Vitals: Pulse 105. Blood pressure 132/157. O2 saturation on 3L nasal cannula is 82% to 89%. Respirations are mid 20s to 30s. Temperature 36.8° C. HEENT: Normocephalic and atraumatic. Extraocular movements are intact. Neck is soft. No cervical adenopathy. Pharynx is without erythema. There are no oral lesions. Cardiovascular: Tachycardia. No murmurs, rubs, or gallops heard. Respiratory: Diminished air movement in bilateral bases. Minimal respiratory wheeze heard. No rhonchi or rales appreciated. Abdomen: Soft, positive bowel sounds, nondistended. The patient complains of positive tenderness to palpation over the right upper quadrant. Musculoskeletal: Strength is 5/5 and equal bilaterally upper and lower extremities. Extremities: No clubbing, cyanosis, or edema. Full range of motion times four. Neuro: Cranial nerves II-XII grossly intact. Sensation is intact.

LABORATORY: Sodium 142, potassium 4.4, chloride 96, CO2 greater than or equal to 41.8, BUN (blood urea nitrogen) 17, creatinine 0.7, and glucose 129. Calcium 8.9. White blood cells 9.7, hemoglobin 15.6, and platelets 202. ABGs (arterial blood gases) from this morning: pH (potential of hydrogen) 7.439, pCO2 (partial pressure of carbon dioxide) 52.9, pO2 (oxygen pressure) 55.2, bicarbonate 35.1, O2 saturation 94% on 3L nasal cannula from 9:30 this morning, when he came in through the emergency department. Chest x-ray from 2 weeks ago revealed extensive opacities on the right side, awaiting results of x-ray from the emergency room this morning. I will review those this afternoon with Dr. Dawson.

ASSESSMENT/PLAN: Pneumonia right-sided in someone with COPD. Patient is oxygen dependent due to chronic respiratory failure. He has been placed on Claforan, Zithromax, and Solu-Medrol as well as a variety of breathing treatments. We will monitor labs, ABGs, and x-ray. See orders for remainder.

CPT CODE(S):  ________________________________________

ICD-10-CM DX CODE(S): ____________________________________

SCIENCE
HEALTH SCIENCE
NURSING
MEDICAL SU 113

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