New Inpatient Consultation
History
Chief Complaint: Nasal bleeding.
History Of Present Illness: Mrs. Bloody nose is admitted to the medicine service for the management of uncontrolled hypertension. She developed a bloody nose last night while watching TV. She describes bright red blood from the right nasal cavity that lasted for 15 minutes. It resolved with pressure and ice. She has never had any previous similar episodes. She denies diplopia, headaches, nasal congestion, or facial pain.
Review Of Systems: Intermittent chest pain, without dyspnea or chest pain.
Past Medical History: Hypertension, hypercholesterolemia, coronary artery disease.
Past Surgical History: None.
Allergies: PCN.
Medications: Lipitor, Toprol, baby aspirin.
Social History: Denies tobacco or alcohol use.
Family History: No bleeding disorders.
Circle the appropriate level:
CC: Documented Not-Documented
HPI: Brief Extended
ROS: Problem pertinent Extended Complete
PMHx, PFHx, PSHx: Problem focused Expanded Problem Focused Detailed Comprehensive
Level of History: Problem focused Expanded Problem Focused Detailed Comprehensive
Physical Exam
Vital signs: BP 195/100 P 90 RR 25
Constitutional: Well developed, well nourished, in no apparent distress. Head: Atraumatic, normocephalic.
Face: No evidence of significant scars, lesions or asymmetries. Facial nerve is intact and equal bilaterally. No sinus tenderness to palpation or percussion.
Eyes: Extraocular movements are intact. Pupils are equally reactive to light.
Ears:The tympanic membranes are clear. External auditory canals are clear bilaterally. External-ear without lesions noted.
Nose: No significant external asymmetry. Septum is deviated to the right with prominent vasculature. Right anterior septum with superficial 3mm ulcer. No masses.
Oral Cavity: Good dentition, no lesions. Tongue is symmetric in motion.
Oropharynx: Symmetric palate, 2+ tonsils. No mucosal lesions.
Hypopharynx and larynx: Mirror exam reveals normal vocal cord motion, no lesions or pooling.
Neck: No adenopathy, thyroid without masses.
How many elements identified by a bullet? __________________________
What level exam is documented? ___________________________________
Medical Decision Making
Data: CT Scan of the sinuses reveals a right nasal septal deviation, paranasal sinuses are clear, no masses, no bony changes.
Serial H/H: Normal and stable.
Impression: Epistaxis.
Plan: Bleeding source likely from Kiesselbach’s plexus, now resolved. Recommend avoid digital trauma, increase humidity, control hypertension and stop aspirin.
Circle the appropriate level:
Data: Minimal Limited Moderate Extensive
Diagnosis: Minimal Limited Moderate Extensive
Risk: Minimal Low Moderate High
Complexity of Medical Decision Making: __________________
Put It All Together
History ________________
Exam ________________
Medical Decision Making ________________
Code Documented ________________