Full Case:
Chief complaint: Syncope.
HPI: A 68-year-old male arrives at the ED in respiratory distress after sudden syncope/collapse while shopping. He is unresponsive. EMS reports a weak pulse, labored respirations, and unresponsiveness.
History: CABG 5 years ago, no chest pain since.
ROS: Unobtainable because the patient is unconscious.
Allergies: None.
Medications: Coumadin.
PMH: Hypertension.
Social: Lives with wife.
Exam/Vitals: BP 82/62, pulse 79, RR 12 and shallow, O2 saturation 90% on high-flow oxygen. The monitor
shows right bundle branch block.
Neuro: Initially, eyes are closed. The patient opens his eyes to questions and responds to some questions,
then later becomes unresponsive.
HEENT: Pupils sluggish and equal; unable to assess EOM/fundus.
Neck: Supple, no JVD or bruits.
Lungs: Mild rhonchi.
Heart: Regular rhythm without murmurs.
Abdomen: Benign.
Extremities: Symmetric, no edema or cyanosis.
Skin: No rash.
Neuro: No focal deficits.
Hospital course: IV x 2; NS 1000 cc bolus with little response; dopamine drip 10-20 mcg/kg/min; O2
saturation drops; respirations slow; patient becomes unresponsive and progresses to cardiac arrest. CPR
is performed, with multiple doses of adrenaline and atropine, defibrillation, ABG showing pH 7.1, bicarbonate x 2, with no effect. The patient is pronounced dead at 13:32.
Critical care time: 77 minutes continuous.
Diagnosis: Cardiorespiratory arrest.
What E/M coding is reported for this encounter?