Sample Charts

Medical Coding Sample Charts:

Radiology Chart

Procedure  Ordered : FCT ABDOMEN WO CONTRAST , FCT PELVIS WO CONTRAST

Admitting DX : RT SIDE PAIN

Working DX : RT SIDE PAIN

CT ABDOMEN AND PELVIS WO CONTRAST

INDICATION : Evaluation with right sided-pain, possible stones. Multiple helical images were performed from the base of the lungs to the proximal third of the femurs without IV or oral contrast administration. There is a small to moderate sized pericardial effusion. There are mild basilar infiltrates. The liver is diffusely increased in the attenuation probably consistent with iorn supplement. There is mild hydronephrosis of the right ureter, which is difficult to trace in the pelvis. This could suggest a small stone on the side distally. Trace amount of fluid seen in the pelvis.

IMPRESSION:

1. Small to moderate sized pericardial effusion.

2. Bilateral lower lobe infilrates.

3. Diverticulosis without evidence of actual diverculitis.

4. Mild right hydronephrosis without clear visualization of the distal right ureter.  There could be a proximal small ureteral calculus on the right side that is not wellvisualized.

5. Trace amount of ascites.

6. Increased attenuation of the liver that could be consistent with iorn supplement.

ICD - 562.10, 591, 423.9, 793.1

CPT - 74150, 72192

Evaluation and Management

VISIT DATE:  06/08/05

PATIENT NAME:  AAABBB

REASON FOR CONSULTATION:

Uncontrolled hypertension.

HISTORY OF PRESENT ILLNESS:

This is a 58-year-old male patient, Asian origin, with history of long standing hypertension and diabetes.  Has had fluctuations in his blood pressure with systolic blood pressure in the 170s to 180s and some times its 120s and 130s.  The patient has had few medications changed before, currently he is on Norvasc 10 mg daily.

PAST MEDICAL HISTORY:

Diabetes for 18 years, hypertension for 18 years, and history of bronchial asthma.

MEDICATIONS:

Norvasc 10 mg daily, metformin 1000 mg b.i.d., glipizide 10 mg b.i.d., Zocor 40 mg daily, aspirin 325 mg daily, and albuterol with breathing inhalers.

ALLERGIES:

No known drug allergies.

SOCIAL HISTORY:

Heavy smoker for many years, reduced smoking little bit now.  Still smokes few cigarettes a week.  No alcohol or drug abuse.

FAMILY HISTORY:

Father had hypertension and died of CVA.

REVIEW OF SYSTEMS:

Positive for nocturia two to three times in the night, also has some sweating and palpitations at times.  Denies any nausea, vomiting, diarrhea, abdominal pain, hiccups, itching, dysuria, frequency or urgency.  Has some headache off and on and dizziness sometimes.  Has shortness of breath all the time, both at rest and with exertion.  Denies  any chest pain.  No fever, chills, rigors or sore throat.  Denies any loss of weight, loss of appetite, extreme weakness or fatigue.

PHYSICAL EXAMINATION:

GENERAL:  The patient is alert, oriented, and not in any acute distress.  Speaks coherently.

VITAL SIGNS:  BP:  121/84.  Heart rate:  84.  Respirations:  15.  Temperature:  96.5.

HEENT:  Normocephalic, atraumatic.  Pupils are equal and reactive to light and accommodation. Extraocular muscles intact.

NECK:  Supple.  No JVD. No lymphadenopathy, thyromegaly, masses or bruits.

SKIN:  Turgor fair.  No icterus, cyanosis or pallor.  Mucosa is moist and pink.

CHEST:  Wall without deformities or tenderness.

CVS:  S1 and S2 regular.  No pericardial rubs.

LUNGS:  Few scattered rhonchi, but has no basilar rales.

ABDOMEN:  Soft.  No abdominal or femoral bruits.  No masses.  No organomegaly.  Bowel sounds present.  No free fluid.

EXTREMITIES:  Trace pitting pedal edema bilaterally.  Peripheral pulses are feeble.

CNS:  Grossly intact with no motor or sensory deficits.  No involuntary movements.

LABORATORY DATA:

Total protein is 7.6, albumin 4.4, cholesterol 194, BUN 17, creatinine 1.1, potassium 5.4; upper limit of normal is 5.5, sodium 141, chloride 100, CO2 26, hemoglobin A1c 8, and UA is not available.

IMPRESSION:

1.      Uncontrolled hypertension with fluctuations.

2.      Long-standing diabetes.

3.      Edema.

PLAN:

Will do a workup for secondary hypertension due to fluctuating blood pressures.  Check urinalysis for protein and microalbumin due to history of diabetes.  Will check a 24-hour urine for metanephrines, normetanephrines, and VMA.  Check serum aldosterone, ACTH, cortisol, renin, TSH, metanephrines, and sed rate.  Advised the patient to keep log of his blood pressure readings during __________ .  I will see him back in about three to four weeks' time with results.

Thanks for the consultation.  Will follow the patient with you.

ICD - 401.9, 250.00

CPT - 99243