Audit Report 1.2 Consultation
LOCATION Inpatient, Hospital
PATIENT: Raymond Hunt
REQUESTING PROVIDER Mohamad Almaz, MD
CONSULTING PROVIDER Ronald Green, MD REASON FORCONSULTATION Opinion regarding preoperative clearance
HISTORY OF PRESENT ILLNESS: A 53-year-old male who hasbeen admitted today to the hospital because of right tibia andfibula fracture. Patient tells me he was walking out when heslipped on the ice and fell. He complains of pain of 5/10 in theright leg. just below the knee joint. He has had a fracture Nohistory of radiation of pain. It is worse with movements Patientworks as a laborer, works on a farm. He says he does mostlyphysical labor He tells me that he never gets any chest pain orshortness of breath, No history of any orthopnea or paroxysmalnocturnal dyspnea No history suggestive of any angina. No historyof any pain going to the left arm at any time with exertion. Nohistory of any headache and blurring of vision. No history of anyCough. No history of fever, chills, or rigors. No history of anyrecent weight gain or weight loss. No history of any pain inabdomen. No history only change in bowel habits. No history of anybleeding per rectum or melena. No history of dysuria, hematuria, orpyuria.
PAST MEDICAL HISTORY
1. Hypertension. 2. Hyperlipidemia
PAST SURGICAL HISTORY: History of hernia repair whenhe was 36 and 46
SOCIAL HISTORY: Still smoking a pack per day. He hasbeen smoking for more than 20 years. The last time he took alcoholwas 22 months ago. He stated he didn’t try really before that.
ALLERGIES
1. Zetia. He could not tolerate the medication, had arash.
2. He is allergic to latex
FAMILY HISTORY Father deceased from stroke at the ageof 39. Also had hypertension.Mother passed away a couple of yearsago. She had history of hypertension and what looks like a massiveheart
attack.
CURRENT MEDICATIONS
1. Aspirin
2 Lisinopril 10 mg daily.
3. He takes herbal medication, red rice yeast, 600 mgtablets twice a day.
4. Omega-3 capsules
REVIEW OF SYSTEMS: A full review of systems whichinclude CARDIAC PULMONARY, GASTROINTESTINAL MUSCULOSKELETAL,Neurologic. ENDOCRINE, RHEUMATOLOGY, IMMUNOLOGY, AND ONCOLOGY wereperformed and negative for symptoms, except for as noted.
PHYSICAL EXAMINATION Patient is alert and oriented totime, ploce, and person. PULSE: 138. RESPIRATORY RATE: 20. BLOODPRESSURE: 120/76 HEAD: Atraumatic. EYES: Pupils are reactive. NOSEand THROAT: Oral Tucosa is slightly dry. NECK Supple. No JVD. Nocarotid bruit. HEART: S1 and S2, regular. LUNGS: Clear toauscultation. ABDOMEN: Soft. Bowel Sounds are positive, nontender,nordistended. EXTREMITIES: Pulses are positive, no clubbing, nocyanosis, no edema in the left lower extremity. Right lowerextremity is in cast. NEUROLOGICAL: Grossly, normal. No focaldeficits. PSYCHIATRIC: Normal mood and affect. SKIN: No acuterashes.
LABORATORY STUDIES AND INVESTIGATIONS: He did havelabs done in January, which show a BUN of 14, creatinine of 0.9,and calcium of 9.3. His cholesterol was 215 at the time withtriglycerides of 32, HDL of 44, and LDL of 154
I did an EKG and reviewed this. This shows normalsinus rhythm but slightly prominent T-waves.
ASSESSMENT
1. Preoperative clearance
2. Hypertension
3. Hyperlipidemia
4. Prominent T-waves on the electrocardiogram
RECOMMENDATIONS
1. Patient is a 53-year-old male with decent exercisetolerance. Patient does have risk factors including smoking,hypertension, hyperlipidemia, and age for his coronary arterydisease but patient does not any exertional angina or exertionalshortness of breath. His EKG does not show any acute changes otherthan some changes in T-waves. At this time, I think he can proceedwith surgery without any further work-up. He can be continued onhis ACE inhibitor for high blood pressure. He will be a mild tomoderate risk for intraoperative an postoperative risk ofmyocardial infarction and heart failure but, at this time, there isno acutely modifiable risk factors as such. I did discuss the riskswith the patient too and he has consented for surgery.
2. Patient does have slightly prominent T-waves on theEKG. We will check a BMP at this time. Check on potassium levels,especially as he is on ACE inhibitor.
3. Patient does have hyperlipidemia and he may becontinued on his current home medications.
4. I did discuss the plan with the patient and also myrecommendations with Dr. Almaz. Some of the old charts arereviewed
5. We also recommend keeping him on DVTprophylaxis.
One or more of the following codes are reportedincorrectly for this case. Indicate the incorrect code orcodes.
PROFESSIONAL SERVICES: Consultation, 99254
ICD-10-CM DX Traumatic tibia fracture, S82.201A:Traumatic Shula fracture S82.401A: Hypertension, 110;Hyperlipidemia, E78.5: Abnomal electrocardiogram, R94.31;Preprocedural cardiovascular examination Z01.810
INCORRECT CODE:
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