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10. History of gouty arthritis with a recent gouty attack in his right first metatarsal phalangeal joint. 11. History of diverticulitis. 12. Hyperlipidemia. 13. Status post cholecystectomy, inguinal hernia repair, appendectomy. 14. Chronic renal failure, post PD catheter placement. ALLERGIES: No known drug allergies. MEDICATIONS: Nebulizer at home. Bumex 2 mg in the morning and 1 mg in the evening. Coumadin 2 mg on Monday, 1 mg on other days. Digoxin 0.125 mg po daily. Potassium chloride 20 mEq po b.i.d. Zocor 10 mg po q.hs. Coreg 25 mg po b.i.d. Allopurinol 100 mg po daily. Ranitidine 150 mg po q.hs. 000 S1Ov LRSI = FAMILY HISTORY: Mother died of pancreatitis. Father died at age 71. Otherwise, family history is noncontributory. SOCIAL HISTORY: Lives here in town with his wife. She was not available today. He quit smoking 16 years ago. REVIEW OF SYSTEMS: CONSTITUTIONAL: No fever, chills, or night sweats. ENT: Resolved upper-respi y tract symp . RESPIRATORY: As mentioned. CARDIOVASCULAR: Exertional dyspnea. No chest pain. GI: Questionable dark stool but no diarrhea, nausea, or vomiting. He had some abdominal discomfort with coughing. MUSCULOSKELETAL: History of gouty arthritis, but seems to be controlled. SKIN: Trace edema. NEURO: Negative. PSYCHIATRIC: Negative. PHYSICAL EXAMINATION: The patient was in mild respiratory distress. He was awake, oriented times three without any focal neurological deficits. His heart rate is in the 70s range, blood pressure has been 120s/80s, sats 92% when he came in, 98% on 2 liters per nasal cannula. Slightly increased jugular venous pressure. No cervical lymphadenopathy. LUNGS: Good air entry bilaterally but expiratory wheezes bilaterally. No crackles. No sacral edema. ABDOMEN: Soft and nontender, no masses. He has PD catheter in the left lower quadrant. Small hematoma in the right inguinal area from his recent aortogram. LOWER EXTREMITIES: Very trace edema. LABORATORY STUDIES: CBC tonight shows a white count of 8.6 thousand, hemoglobin 12.3, platelets 140,000, BUN 29, sodium 139, potassium 3.6, chloride 98, bicarb 31, creatinine 2.2, calcium 8.5. BNP 536 picogram/ml. INR 1.5 with a pro-time of 14.3. Digoxin 0.6. Troponin-I less than 0.04. His last uric acid level was 7.4. IMPRESSION: 1. Exacerbation of COPD/asthma with wheezes. 2. Abdominal aortic aneurysm. PLAN: 1. Albuterol MDI 2 puffs ti.d. 2. Atrovent MDI 2 puffs t.i.d. 3. Azmacort MDI 2 puffs b.i.d. 4. Solu-Medrol 80 mg IV q8h. 5. Continue the current PO medications. 6. Zithromax 500 mg IV daily. 7. The patient is code level 1. Discussed all of the above with the patient. He seems to understand and agrees with the plan.Will discuss further issues to his abdominal aortic aneurysm and further plans with his positive stress test when the rest of the family is available in the next couple of days. T1.2: SERVICE CODE(S): 99221 ICD-10-CM DX CODE(S): RO6.02, J44.1, 150.9 INCORRECT/MISSING CODE(S): ANS: Next Step Advanced Medical Coding and Auditing 2017 2018 Edition 1lst Edition Buck Test Bank INCORRECT/MISSING CODE(S): 99218, R06.02, 171.4 RATIONALE: The HPI was a level 4 and contains the 4 elements of quality (progressive), context (URI 1 week ago), duration (4 days), and associated signs and symptoms (nasal drainage, cold-like symptoms, SOB). The ROS is a level 3 (8 elements) and includes constitutional, otolaryngologic, cardiovascular, respiratory, g i I, musculoskeletal, logic, and psychiatric. Note that skin is not counted as an ROS due to the fact that “trace edema” is an objective (examination) finding. All three of the PFSH elements were reviewed, making this a level 4 PFSH. The HPI, ROS, and PFSH elements make this a level 3 or detailed history. The examination included three elements of constitutional (general app« 8 / 9 : : respiratory distress, blood pressure, and heart rate) so this will count as o0 The body areas were abdomen (soft), neck (increased jugular venous pres. BAs. There were 6 organ systems: cardiovascular (edema), respiratory (wheezes), gastrointestinal (no masses), integumentary (exam dialysis catheter site with noted hematoma), neurologic (oriented, no deficits), and lymphatic (Ilymphadenopathy) for a total of 9 BAs/OSs, which would make this a level 4 or comprehensive examination; however, BAs are not counted in determining a comprehensive level examination.With a total of 7 OSs, this examination is a level 3 or detailed examination. The MDM elements included limited diagnosis management options, moderate data to review, and a moderate risk to the patient, making this a moderate MDM or level. The detailed history, detailed examination, and moderate MDM are reported with 99218. The diagnosis on admi. was progressive shortness of breath, but upon examination the diagnosis changed to an exacerbation of COPD with asthma (J44.1). This is the diagnosis to assign and not the shortness of breath since the SOB (R06.02) is a symptom