View MR 099407
MR 099407
Emergency Department Visit
Chief Complaint: VOMITING.
This started just prior to arrival and is still present. He has had nausea and vomiting. No diarrhea, black stools, bloody stools, or abdominal pain. Patient is diabetic and has been having elevated blood sugars at
320 mg/dL.
REVIEW OF SYSTEMS: Unobtainable due to patient's altered mental status.
PAST HISTORY: Poorly controlled diabetes mellitus, with history of poor compliance.
Medications: See nurses' notes.
Allergies: PCN.
SOCIAL HISTORY: Nonsmoker. No alcohol use or drug use.
ADDITIONAL NOTES: The nursing notes have been reviewed.
PHYSICAL EXAM
Appearance: Lethargic. Patient in mild distress.
Vital Signs: Reviewed. Patient is tachycardic.
Eyes: Pupils equal, round, and reactive to light.
ENT: Dry mucous membranes present.
Neck: Normal inspection. Neck supple.
CVS: Tachycardia. Heart sounds normal. Pulses normal.
ED Course:
Insulin IV drip per protocol at 10 units/hr.
Zofran 8 mg IV push at 01:33 on Jul 13, 2008.
Phenergan 25 mg IV push at 07:52.
Discussed case with physician, Dr. X. Reviewed test results. Agreed upon treatment plan. Physician will see patient in hospital.
Total critical care time: 45 minutes.
Disposition: Admitted to Intensive Care Unit. Condition: Stable.
Admit decision based on need for monitoring, IV hydration, and medications.
CLINICAL IMPRESSION: Vomiting; diabetic ketoacidosis with dehydration.
What E/M code is reported for this encounter?