E&M Code for Discharge Day Management, Primary Dx, and 8 (!) Secondary Diagnoses!

Inpatient Discharge Summary
Patient Case Number: IPDC05-Morgan, John
Patient Name: John Morgan	DOB: 04-16-75	Sex: M
Date of Admission: 12-03-XX	Attending Physician: Xavier Hamilton, MD
Date of Discharge: 12-05-XX

ADMISSION DIAGNOSES:

Intractable confusion.

Elevated ammonia.

Hypertension.

Dyslipidemia.

Obstructive sleep apnea

DISCHARGE DIAGNOSES:

Reactive confusion combined with being "mentally stressed out".

Hypertension.

Dyslipidemia.

Obstructive sleep apnea.

Fatty liver.

Elevated ammonia level of unclear etiology.

B12 deficiency

BRIEF ADMITTING HISTORY AND PHYSICAL:

A 43-year-old Caucasian male with a past medical history of TIA, carotid stenosis, hypertension, dyslipidemia, hypogonadism, anemia, obstructive sleep apnea, and low back pain, presented to the emergency room on 12-03-XX with a chief complaint of confusion. His wife has noted that he has been confused and losing track of his whereabouts.

The condition was of insidious onset but he had similar shorter spells if the past. Initial workup in the emergency room was done including a CT scan of his head that was negative for any acute process. CT perfusion studies have also been done and they were negative as well. He was admitted to the hospital for further workup and management.

HOSPITAL COURSE: In the hospital, the patient was admitted to the general medical ward, was put on careful neurological examination. The patient was seen by neurology and an MRI of the brain was done and was negative for any acute process. There was scattered chronic white matter ischemic changes with nothing acute. His ammonia level was noted to be slightly elevated, highest at 40, and we did not have a good explanation for that, so we did liver ultrasound to rule out cirrhosis. He was found to have dense fatty infiltration however no cirrhotic appearance and the radiologist recommended that we do an MRI. An MRI of the abdomen was done with and without contrast and again, there was no evidence of cirrhosis but the fatty infiltration was again detected. He was noted to have minimal splenomegaly and that is probably of no significance but may need to be watched closely. The patient was seen by Dr. Warren and both him and I shared the impression that this is likely reactive confusion secondary to stress. The patient has slightly improved during this hospitalization. We did put him on lactulose and his ammonia level started to come down. His confusion was noted to improve as well but he was not fully back to his baseline. He and his wife felt that it would better go home and be observed there for the next few days to avoid any further stress at the hospital.

He was cleared for discharge by neurology. We had a lengthy discussion with the patient and his wife about his condition. I explained to them also that this might be related to primary brain disease and that may need further workup and even referral to tertiary centers where more dedicated workup could be ran by a specialist over there. They understand this recommendation. I explained to them that we have to keep him under observation even at home and would rather not leave him alone for the next few days until he hopefully recovers and gets back to his baseline.

The patient was noted to have a profoundly low vitamin B12 deficiency. The patient was started on parenteral B12 injections while in the hospital. He will go home on six weeks of parenteral B12 injections weekly.

Vitals:

Temperature	98.6F
Pulse	68

Respirations	20
Blood Pressure	130/80
SpO2	96% on room air

PHYSICAL EXAMINATION:

GENERAL: In no acute distress. Awake, alert, and oriented times three.

HEAD, EYES, EARS, NOSE AND THROAT: Head is normocephalic and atraumatic. Pupils equal, round and reactive to light and accommodation. Extraocular muscles are intact. No jugular venous distention.

NECK: Supple. No thyromegaly. No tracheal deviation.

CHEST: Clear to auscultation. No crackles or rhonchi.

HEART: S1 plus S2. Regular rate and rhythm. No audible murmurs. ABDOMEN: Soft. Positive bowel sounds. No rigidity. No tenderness. EXTREMITIES: No edema. Peripheral pulses are equal.

SKIN: Grossly intact. No pallor, cyanosis, clubbing or jaundice. NEUROLOGIC: Awake, alert and oriented times three. Motor, sensory and cranial nerves are grossly intact.

Labs and medications have been reviewed.

DISCHARGE INSTRUCTIONS:

The patient will be discharged home in a stable

FOLLOWUP: Follow up with the primary care physician in one week. with Dr. Warren.

ACTIVITY: As tolerated.

CONDITION AT THE TIME OF DISCHARGE: Stable.

Time spent arranging for discharge today was in excess of 35 minutes.

Electronically Signed By: Xavier Hamilton, MD

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