Sample E/M Charts

           

Sample/Practice/Free Evaluation and Management (E/M) Charts/Reports

E/M CASE STUDY 1:

PATIENT NAME:  _____________

SUBJECTIVE:

This is a 32-year-old African-American female, who has a history of lupus nephritis and is currently on peritoneal dialysis, who comes back for followup visit.  She reports no symptoms of chest pain or shortness of breath.  She denies any nausea or vomiting and she states that she has a good appetite.  She does report some minimal weight gain about three pounds in the past one month.  Her ultrafiltration is good according to the cycler readings, which was about 1600 cc.  She is currently on 4.25% bag of dextrose and 2.5% bag of dextrose used together at night.  She also does a mid day exchange with a 2.5% dextrose bag.

OBJECTIVE:

VITAL SIGNS:  Weight:  148 pounds.  Blood pressure:  122/80 mmHg.  Pulse:  72 per minute and regular.  Temperature:  96.5.  The patient also reported home blood pressures to be about 130/90 to 94 mmHg.

CVS:  Regular rate and rhythm.

LUNGS:  Clear.

ABDOMEN:  Soft with normal bowel sounds.  PD catheter site was clean with no evidence for infection.

EXTREMITIES:  No edema.

ASSESSMENT:

1.      End-stage renal disease.

2.      Lupus nephritis.

PLAN:

She continues to do well.  Her recent Kt/Vs have all been acceptable.  Her blood pressure measurement in the office today was under control, but her home blood pressures reflect higher diastolic blood pressures.  She has no evidence for volume overload.  She has no extremity edema.  Her hemoglobin levels have dropped since her previous blood tests in July.  She has been instructed to increase the dose of Epogen to 10000 unit q. weekly.  Her phosphorus levels are decreasing.  All other labs appear to be within normal limits.  I advised her to continue on her current PD prescription.  The only change to her medication was; I have increased Norvasc to 10 mg once a day for better blood pressure control.  We plan to see her back in followup in one month time.

ICD: 585.6, 710.0, 583.81

CPT: 99213

E/M CASE STUDY 2:

DATE OF SERVICE:  08/18/05

PATIENT NAME:  ___________

SUBJECTIVE:

End-stage renal disease, patient on dialysis.  His Kt/V is 1.59, phosphorus is 3.1, potassium is 3.7, albumin is 3.7.  Blood pressure is stable and he is doing well on dialysis.

OBJECTIVE:

VITAL SIGNS:  BP:  110/62.  Pulse:  76 per minute.  Temperature:  97.4.  Weight 120 pounds.

CVS:  S1 and S2 regular.

LUNGS:  Clear.

ABDOMEN:  Soft.

EXTREMITIES:  No edema.

IMPRESSION:

3.      End-stage renal disease.

4.      Hypertension.

5.      Parkinson disease.

PLAN:

Continue dialysis.  Discussed again with the patient and his wife about AV fistula.  The patient is very sure that he does not want any surgeries or needles and that he will just have Permacath as long as it works.  Explained about serious infections with prolonged Permacath presence for dialysis and the patient still does not want to go to vascular surgeon.  He will continue to reinforce the issue about catheter-related serious infections.

ICD:  403.91, 585.6, 332.0

CPT:  99213

E/M CASE STUDY 3:

VISIT DATE:  08/17/05

PATIENT NAME:  ___________

SUBJECTIVE:

The patient underwent renal biopsy, which was not confirmatory.  Biopsy specimen sample very limited.  However, we called hepatologist and discussed about the biopsy specimen.  He took an another look and said there were some effacement of food process and some changes suggestive of FSGS also.  However, I do not want to start him on any steroids at this point.  His proteinuria has significantly reduced from 12 grams in June of 2005 to 3.382 mg per g of creatinine.  Biopsy specimen was suggestive of mild effacement of food processes and possible FSGS.  However, his creatinine remains stable and urine protein level has significantly dropped.  The patient continues to have swelling in both his legs, and he is taking 80 mg of Lasix in the morning and 40 mg of Lasix in the evening.  He is on the maximum dose of valsartan 320 mg daily.  Blood pressure is still on the higher side.  The patient keeps log of his blood pressure readings.

OBJECTIVE:

VITAL SIGNS:  BP:  154/70.  Pulse:  76 per minute.  Weight:  190 pounds.

CVS:  Regular.

LUNGS:  Clear to auscultation.

ABDOMEN:  Soft.

EXTREMITIES:  Bilateral pitting pedal edema 3 to 4+.  Peripheral pulses not palpable because of edema.

IMPRESSION:

6.      High-grade proteinuria, etiology is still unclear.

7.      Renal biopsy showed some evidence of minimal change disease and possible FSGS.

8.      Hypertension, needs better control.

PLAN:

Will check a sed rate again.  Previous sed rate was slightly on the higher side.  Will do a 24-hour urine for creatinine clearance and protein, BMP, magnesium, and phosphorus.  Will see the patient back in about four weeks' time.  Start Altace 5 mg once a day.  Will maximize the dose for antiproteinuric effect.  There is no indication to start steroids or immunosuppressive agents based on the limited biopsy report.  Will consider doing the renal biopsy, if proteinuria is not responding to medications or if renal function deteriorates.  Explained to the patient that this blind procedure and adequate sample was not available for most accurate diagnosis.  The patient understands this and he will agree for another biopsy if necessary in future.  Creatinine clearance is well preserved at this point.

ICD: 791.0, 401.9, 782.3

CPT: 99214

E/M CASE STUDY 4:

VISIT DATE:  08/10/05

PATIENT NAME:  ____________

SUBJECTIVE:

This is a 51-year-old who has been referred to us for evaluation of hematuria/proteinuria.  The patient was reporting that she noticed increased extremity swelling sometime in June of this year.  She presented to your office in late July with persistent extremity swelling and intermittent shortness of breath.  She said she also noticed 10 to 12 pound weight gain.  She was recently started on Lasix, which seems to have alleviated some of her symptoms.  She was also found to have proteinuria and hematuria on a routine urinalysis.  She did say that she was treated for UTI once in January when she was prescribed Bactrim and most recently about a week back when she was given a course of amoxicillin.  She denies any previous history of fever, chills or any form of upper respiratory infections.  She also denies joint pains and arthralgias or any other form of skin rashes. She does report some increased tiredness.

PAST MEDICAL HISTORY:

Significant for recently diagnosed hypertension, which was noticed when she presented with extremity swelling and she was also found to have elevated cholesterol levels in December 2004.

CURRENT MEDICATION:

Verapamil 100 mg one tablet once a day, Lasix 40 mg one tablet once a day, potassium supplements 20 mEq once a day, lipitor 40 mg one tablet once a day, calcium 1000 mg one tablet once a day, and a baby aspirin 81 mg one tablet once a day.

FAMILY HISTORY:

Positive for coronary artery disease in her father and stroke in her mother.  She denies any family history of kidney diseases.

REVIEW OF SYSTEMS:

Positive for hematuria and proteinuria.  Negative for nausea, vomiting, abdominal pain, fever, chills, weight loss, headache, dizziness or vision changes.

PHYSICAL EXAMINATIONS:

VITAL SIGNS:  Blood pressure:  124/68 mmHg.  Weight:  192 pounds.  Pulse:  81 per minute and regular.  Temperature:  98.3 degrees fahrenheit.

HEENT:  Sclerae anicteric.  Oral mucosa is moist.

NECK:  Exam does not reveal any elevation in the jugular venous pulse.

CVS:  Regular rate and rhythm with no murmurs, rubs or gallops.

LUNGS:  Clear bilaterally.

ABDOMEN:  Obese with normal bowel sounds.

EXTREMITIES:  3+ edema bilaterally.

ASSESSMENT/PLAN:

9.  Hematuria.

10. Proteinuria.

The constellation of findings of peripheral edema associated with hypertension and recent diagnosis of hyperlipidemia is suspicious for the nephrotic syndrome.  Unfortunately, I was not able to read the numbers of the recent 24-hour urine protein quantification since it was not legible coming through the fax machine.  I have requested another copy of that from your office. I have ordered multiple serologies as well as her renal ultrasound.  I plan to see the patient back in followup in two weeks' time.  If she has significant proteinuria associated with hematuria, we might have to consider renal biopsies depending on the serologies to exclude glomerulonephritis.  I have also requested the patient to get an appointment with the urologist as ordered by you.  I said that it should be okay if she could see him after her appointment with me in two weeks' time.  We first need to exclude medical diseases of the kidney.  I will keep you posted on further progress in this case.

ICD: 599.70, 791.0, 782.3

CPT: 99203

E/M CASE STUDY 5:

VISIT DATE:  08/23/05

PATIENT NAME:  _____________

REASON FOR CONSULTATION:

Renal failure.

HISTORY OF PRESENT ILLNESS:

This is a 63-year-old who has been referred to us for evaluation of renal insufficiency.  The patient comes in today with no complaints of chest pain or shortness of breath.  She does report some symptoms of occasional tiredness.  She denies any recent fever or chills and she has never had any form of hematuria or dysuria.

PAST MEDICAL HISTORY:

Significant for diabetes of one year duration, hypertension of 30 to 40 years duration, hyperlipidemia, hysterectomy for an uterine malignancy in 1989, and degenerative joint disease requiring multiple surgeries as well as cholecystectomy.  She also gives a history of prolonged use of non steroidal anti-inflammatory drugs including prescription Motrin, which she used for 20 years, which was followed by celebrex and Bextra.  All these medications were stopped one year back.  She denies any previous history of MIs or strokes.

CURRENT MEDICATIONS:

Glipizide, Avandia, Lipitor, and Norvasc, dosages were not available at the time of dictation.

ALLERGIES:

She reports no known drug allergies.

FAMILY HISTORY:

Positive for diabetes.  She denies any family history of hypertension or kidney diseases.

REVIEW OF SYSTEMS:

Positive for some tiredness.  Negative for nausea, vomiting, abdominal pain, hematuria, dysuria, fever, chills, weight loss, headache, dizziness or vision changes.

PHYSICAL EXAMINATIONS:

VITAL SIGNS:  Pulse:  82 per minute and regular.  Temperature:  97.8.  Blood pressure:  162/64 mmHg on initial exam and subsequently two blood pressure measured were 122/68 and 126/66 respectively.

HEENT:  Sclerae anicteric.  Oral mucosa is moist.

NECK:  Exam does not reveal any elevation in the jugular venous pulse.  There was left sided carotid bruit.

CVS:  Harsh systolic murmur heard best in the aortic area.

LUNGS:  Lungs had bilateral respiratory wheeze.

ABDOMEN:  Obese with normal bowel sounds and no bruits.

EXTREMITIES:  1+ pitting edema bilaterally.

LABORATORY DATA:

Most recent labs which were done on 08/04/05 were as follows:  Sodium was 139, potassium of 4.3, chloride of 99, bicarbonate of 25, BUN was 31, and creatinine of 1.7.  Triglycerides were 144, total cholesterol was 196, HDL was 51, and LDL was 116.

ASSESSMENT/PLAN:

11. Hypertension.

12. Diabetes.

13. Chronic kidney disease.

The patient's current elevation in creatinine is probably reflective of chronic kidney disease.  This could be secondary to a combination of hypertension/diabetes related to kidney disease.  She also could have developed interstitial nephritis from chronic nonsteroidal anti-inflammatory drug use.  Atherosclerotic renovascular disease is another possibility given her history of hyperlipidemia, hypertension, and clinical evidence of carotid bruit.  We need to quantify whether she has any significant proteinuria.  Her previous microalbumin to creatinine ratios have not shown any significant microalbuminuria.  I have ordered a 24-hour urine collection for protein quantification as well as estimation of creatinine clearance.  I have also requested a renal ultrasound and urine immunofixation as well.  The patient is to get above mentioned tests done over the next three to four weeks and then she will come back for a followup visit with me.  Her blood pressures are extremely well controlled, and I have advised her to continue on her current medications.  If her urine protein quantification does show that she has significant proteinuria, we might have to change her medications to accommodate ACE inhibitor.  She is on Dyazide currently.  Her potassium levels are within acceptable limits.  If she has any elevation in her potassium, we might have to discontinue the triamterene and Dyazide and continue the HCTZ, because of the risk of hyperkalemia.  Will see her in followup in four weeks' time.

ICD: 403.90, 250.00, 585.9

CPT: 99243