Emergency Department HISTORY CHIEF COMPLAINT SOB with diaphoresis...

 Emergency Department



SOB with diaphoresis intermittent for the last 12 hours and EKG en route to hospital showing 3-4 mm ST segment elevations in V4 through V6 with T-wave inversion in V4 through V6 and an inferior wall MI of indeterminate age.


This is a 71-year-old Japanese female with a long-standing history of hypertension and heart problems since the age of 48 who was admitted to the coronary care unit to rule out acute lateral wall myocardial infarction. Her cardiac problems began with episodes of chest pain 23 years ago, and she was medically managed by a cardiologist in Japan. Last year, she moved to the United States and was free of symptoms until March of this year, when she presented to Weston Medical Center with chest pain and SOB. She was found to have evidence of acute ischemia and was given thrombolytic therapy, which was complicated by hemorrhage from a peptic ulcer. In addition, she was noted to have congestive failure and renal failure. She underwent coronary catheterization that revealed a 95% lesion of the LAD with an ejection fraction of 47%. After medical management, she was discharged home. Five days later, she began developing shortness of breath and diaphoresis and was brought by ambulance to our facility where an EKG showed ST elevation and T-wave inversion in V4 through V6 and an inferior wall MI of indeterminate age. She was started on nitrates and diltiazem with relief of her symptoms. The chest x-ray revealed pulmonary edema with a widened mediastinum consistent with a tortuous aorta, unable to rule out a dissection. A chest CT scan revealed evidence of dissection. She was transferred to the coronary care unit for hemodynamic monitoring and possible coronary catheterization. This is a summary of the information obtained from medical records requested by the attending physician to review.


Medications: The medications she was taking at the nursing home include: Amphojel 30 mL p.o. q.i.d., Carafate 1 g q.i.d., FeSo4 325 mg t.i.d., Halcion 0.125 mg p.o. h.s. p.r.n., Pepcid 20 mg 2 q.h.s.

Illness: Peptic ulcer disease, documented by endoscopy. She also had a long-standing history of hypertension. She has a long-standing renal failure, although this has never been clearly documented in her prior hospital records, and her records from Japan are unavailable. She has an aortic aneurysm documented by abdominal CT in her most recent hospitalization at Weston Medical Center as well as previous cardiac catheterization at that time. There was no history of diabetes, cough, fever, PND or hypercholesterolemia.

Social history: The patient was born in the United States but lived in Japan most of her life. She has smoked 1 pack per day of cigarettes for a year.

Family history: There is no family history of heart disease.


Except as noted in HPI, noncontributory.


GENERAL: The patient appears well-groomed, anxious and oriented x 3.

VITAL SIGNS: 130/90. Respirations: 20. Heart rate: 95. Temperature: 98 °F.

HEENT: Normocephalic, atraumatic. PERRLA. Fundi positive for AV nicking and narrowing. No flame-shaped hemorrhages are seen.

NECK: Supple. Jugular venous distention at 10 cm. No carotid bruits.

CHEST: Heart: Soft S1. Normal S2. S3 and S4 present. No murmurs. Lungs: Coarse, wet rales to halfway up from the bases.

ABDOMEN: Soft, nontender, without organomegaly. There is a 5-6 cm pulsatile abdominal mass in the right upper quadrant in the midclavicular line, just inferior to the umbilicus.

NEUROLOGIC: No focal abnormalities. Cranial nerves II-XII are intact.


1. Inferior wall myocardial infarction, new episode.

2. Peptic ulcer, stable on current medications.

3. Probable renal insufficiency.

4. Congestive heart failure.

5. Hypertension.


Since the patient has had a previous history of GI bleeding with thrombolytic therapy, we will hold heparin. Patient is admitted to restart nitrates and diltiazem and consider captopril for afterload reduction. Rule out an acute myocardial infarction with serial EKGs and CPK isoenzymes. A gated nuclear study is planned to look for focal areas of akinesia. SMAC with BUN and creatinine to evaluate renal status. Monitor BUN and creatinine q.12 h. in view of the patient's recent contrast dose for cardiac catheterization. Continue her Lasix therapy as well.


Answer & Explanation
Verified Solved by verified expert

CPT code: 99205

Step-by-step explanation

A. History

  • (+) chief complaint
  • History of present illness (HPI) is extended (4 elements or 3 chronic conditions): (a) long-standing history of hypertension, heart problems, congestive failure and renal failure
  • Past, family, social history (PFSH): Complete
  • Review of systems (ROS): Complete
  • HISTORY TYPE: Comprehensive (COMP)

B. Examination: Problem focused (PF) 

  • All bullets in Constitutional and Psychiatric  boxes and 1 bullet in Musculoskeletal  box: Comprehensive (COMP)

C. Medical Decision Making

  • Problem Points: New problem (to examining physician); additional workup planned*: 4 points
  • Data Points: Review and/or order of clinical lab tests (1 point); Review and/or order of tests in the medicine section of CPT (1 point) ; Independent visualization of image, tracing, or specimen itself (2 points)
  • Table of Risk: High (Drug therapy requiring intensive monitoring for toxicity)
  • Complexity of Medical Decision Making: High

(Requires 3 of 3)New patient office: 

CPT code: 99205 :

(History: Comprehensive history and exam, and high medical Decision Making.)