Patient Information

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ormat: MM-DD-YYYY)

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Chief Complaint:

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CPT/ICD-10:

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Student Comments:

THIS IS A 64 YEAR-OLD FEMALE PRESENT TO CLINIC COMPLAINING OF ABDOMINAL PAIN AND UNCONTROLLED HYPERTENSION. GENERAL: OBESE HISPANIC FEMALE WITH LIMITED DISTRESS DUE TO ABDOMINAL PAIN HEENT: HEAD IS NORMOCEPHALIC, ATRAUMATIC, PUPILS EQUAL, ROUND, REACTIVE TO LIGHT, ANICTERIC SCLERAE. NECK: SUPPLE, NO JVD, NO CAROTID BRUIT, NO THYROMEGALY. CHEST: SYMMETRY WITH SLIGHLY DIMINISHED BREATH SOUNDS AND SCANTY RALES, NO RHONKI, NO WHEEZES CARDIOVASCULAR: PATIENT NOTICED TO BE SINUS BRADYCARDIC. S1,S2 HEARD. NO MURMURS, NO RUBS OR GALLOPS. ABDOMEN:FULL AND OBESE. NORMOACTIVE BOWEL SOUNDS. NO ORGANOMEGALY. NO CVA TENDERNESS. NO ASCITES. NO GUARDING. EPIGASTRIC PAIN TO PALPATION. EXTREMITIES. NORMAL ROM, NO JOINT INDURATION OR SWELLING. NEUROLOGIC: PATIENT IS CONSCIOUS, ALERT, ORIENTED TO TIME, PLACE AND PERSON. CRANIAL NERVES II-XII GROSSLY INTACT WITH NO FOCAL NEUROLOGICAL DEFICIT. MOTOR AND SENSORY MODALITIES APPEAR GROSSLY INTACT. SKIN: PATIENT DOES NOT HAVE ANY OVERT OR INTEGUMENTARY CHANGES. V/S. TEMP: 97.6, HR: 55, RR 20, BP: 196/88, O2 SAT:96 RA PAIN LEVEL 8/10.

Patient Age:

64 Years

Patient Sex:

Patient Ethnicity:

Hispanic or Latino

ABDOMINAL PAIN & UNCONTROLLED HYPERTENSION

PLAN OF CARE:

UNCONTROLLED HYPERTENSION: WILL TREAT ABDOMINAL PAIN FIRST
CHECK BP MANUALLY ON BOTH SIDES
TITRATED UP BB,CCB, CLONIDINE TO TARGET BP SYSTOLIC 140.
ABDOMINAL PAIN: COULD BE GASTRITIS, VS PANCREATITIS VS ACS
MORPHINE AS NEED, PPI
CT ABDOMEN AND PELVIS W/O CONTRAST ORDERED
R/O ACS WITH EKG AND TROPONIN
LIPASE LEVEL.
HEMATOLOGY BASIC LABS
CHEMISTRY COMPREHENSIVE LABS

CPT/ ICD code: I16. 0 is a billable/specific HYPERTENSIVE URGENCY/R10. 9 – Unspecified abdominal pain. ICD-10-CM.

CPT should be based on diagnostic test.

Note: I need 105 patient encounters. You may come with your own chief complaint and you may also refer to list attached. Patient age should be 18 or older