Inpatient Medical Coding: Sample IP chart 1 Progress Notes

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PROGRESS NOTES

03/16

Neurosurgery Consult Note

chief complaint

No chief complaint on file.

AAABBB is a 32 Y female patient who presents with headaches, syncopal event. Found to have an unruptured giant left MCA aneurysm.

Patient Active Problem List:

ALCOHOL INTOXICATION

LEUKOCYTOSIS

MODERATE ALCOHOL USE DISORDER

CERVICAL HIGH RISK HPV TEST POSITIVE

ALCOHOLIC CIRRHOSIS

METABOLIC ACIDOSIS

HYPONATREMIA

NONRUPTURED CEREBRAL ANEURYSM

Imaging: Abnormal findings left MCA aneurysm with vasogenic edema, no sign of rupture.

NEUROLOGICAL EXAM:

MENTAL STATUS: alert and oriented

SPEECH: Speech normal pattern, fluent, no dysphasia or dysarthria

CRANIAL NERVE: II: visual fields full to confrontation. Optic discs appear normal

III, IV,VI: full extraoccular movements without nystagmus. Pupils equal, round, reactive to light.

V: facial sensation normal to light touch and pinprick bilaterally

VII: facial strength normal and symmetric

VIII: intact to finger rub bilaterally;

IX, X: palate lifts in the midline

XI: sternocleidomastoid strength normal and symmetric

XII: tongue protrudes in the midline, no atrophy or fasciculations.

MOTOR EXAM:Motor exam shows normal stength throughout all 4 extremities. No obvious drift or weakness on my exam

SENSORY: nl LT

Assessment/Plan: 32 Y patient with giant left MCA aneurysm

1) discussed finding in detail

2) answered questions

3) based on size and location, 5yr risk of rupture is estimated at 40%

4) discussed that blood pressure and nicotine are the controllable risk factors. Avoid nicotine and keep blood pressure normal

5) discussed treatment options. Will need to approach this as a team, will discuss with my colleagues. Options are clipping/reconstruction with possible bypass or stent coiling

6) decadron 4mg q6, then taper in 1-2 day over 1 weeks time

7) will likely plan treatment on outpatient. obs in unit.

03/17

NEUROCRITICAL CARE PROGRESS NOTE

Brief Patient ID:

32 y/o F w/ PMHx of moderate ETOH use presenting with nausea, vomiting, and multiple syncopal episodes. Head imaging revealed a large unruptured L MCA aneurysm. Transferred to NNN for neurosurgical care. DSA completed on 3/6/22 which showed a 29 mm distal M1 segment left MCA aneurysm. Patient neurologically intact with only a subtle R UE drift.

Events:

3/6 - txf for active but unruptured aneurysm - DSA done

3/7 - NAEO. Remains neurologically intact and on Decadron taper per NSGY.

Subjective:

No new complaints. Headache improved and nausea resolved. Tolerating PO diet.

Objective:

Intake/Output Summary (Last 24 hours) at 3/7/2022 1013

Last data filed at 3/7/2022 0946

Gross over last 24 hours

Intake 1062.67 ml

Output 1600 ml

Net -537.33 ml

Neurological Exam:

GCS = E:4 V:5 M:6

Mental Status: Alert and oriented x 3, memory, attention, concentration and language intact.

Cranial Nerves: PERRL, visual fields intact to confrontation. EOMI without nystagmus. Face symmetrical at rest and during expression. Face sensation intact to light touch in V1, V2, and V3 distributions. Hearing grossly intact and symmetrical. No dysarthria. Tongue extends straight and palate rises evenly. SCMs strong bilaterally.

Sensory: Intact to light touch x 4

Motor: Normal tone and no tremor. Moves all extremities. Subtle RUE pronator drift noted. Strength 5/5 otherwise.

Reflexes: Patella and biceps 2+ bilaterally; no clonus. Plantar reflex is downgoing.

Cerebellar: No ataxia on finger-to-nose, heel-knee-shin.

Gait: Not tested due to

Assessment and Plan:

Active Hospital Problems

Diagnosis

• (Principal) NONRUPTURED CEREBRAL ANEURYSM

• ALCOHOLIC CIRRHOSIS

• METABOLIC ACIDOSIS

• HYPONATREMIA

• LEUKOCYTOSIS

#. Symptomatic unruptured L MCA M1 aneurysm (3 cm wide) without SAH - s/p CTA, MRI and DSA. Currently awaiting a plan for her aneurysm repair with NSGY v/s NIR. Stable neurologically and of drips.

-- SBP goal 100-140 mmHg

-- Na goal - 135-145 (3% stopped and can trial salt tabs to maintain eunatremia)

-- OK to relax neurochecks to Q2H and transfer to floor

-- Awaiting operative plan v/s IR plan for aneurysm repair which could be at this admission or as an outpatient. NPOpMN if she gets procedure tomorrow

-- Regular diet. NPO past midnight for tomorrow.

-- Decadron taper per NSGY

#. Hx of alcoholism

-- CIWA nursing assessments

-- Thiamine and Folate

#. Tobacco consumption

-- Nicotine replacement

03/07

Neurosurgery

Patient feels better, less headache. No obvious weakness. Emotional

Exam:

Awake and alert

Fluent speech

CN EOMI PERRL FS TM

Strength MAE full, no obvious drift on my exam

Sensation intact LT

Assessment/Plan: s/p Procedure(s):

ANGIOGRAM

1) reviewed films with colleagues, Dr. AAA and Dr. ZZZ Looked at the surgical options in detail and discussed the risks and benefits in detail. Surgery has a high risk of lenticulostriate injury. Would likely require high flow bypass with proximal ligation. Unlikely to be able to reconstruct the MCA based on the size. The long term success might be slightly better than endovascular success, but this is uncertain. Surgery may prevent vaso-vasorum growth of vessel wall. Surgery would have higher up front risks. I discussed these concerns with the patient. In particular there would be risk of stroke and aphasia or right sided weakness. Our thoughts are that a pipeline/coil would not necessarily burn bridges for surgery

2) discussed case with Dr. AAA, discussed his concerns. He could treat this with stent coil , there is risk of continued growth and stroke. Long term treatment may not be successful and she may need further treatments

3) I discussed the pros and cons of both endovascular treatment and surgical treatment. The patient favors a stent coil after our discussion. She would rather have less up front risk and get home sooner. She is aware of potential continued growth.

4) I contacted Dr. AAA and let him know of her wishes.

5) answered all her questions.

6) NPO after MN

7) ok for NOU

03/08

Brief Patient ID:

Events:

3/6 - txf for active but unruptured aneurysm - DSA done

3/7 - NAEO. Remains neurologically intact and on Decadron taper per NSGY.

Subjective:

Patient awake, headache improved, bit anxious about procedure

Assessment and Plan:

Neuro; Symptomatic unruptured L MCA M1 aneurysm (3 cm wide) without SAH - s/p CTA, MRI and DSA. Currently awaiting a plan for her aneurysm repair with NSGY v/s NIR. Stable neurologically and of drips.

-- SBP goal 100-140 mmHg

-- Na goal - 135-145 on salt tabs

--Neurosurgery Dr BBB and Neuro IR consult appreciated. Plan for coil embolization per Dr AAA note yesterday. Received ASA and Brilanta in preparation

-- NPO for procedure

-- Decadron taper per NSGY

ETOH use; no signs of withdrawal

-- CIWA nursing assessments

-- Thiamine and Folate

Smoking;Tobacco consumption

-- Nicotine replacement, counseled

DVT proph; SCD

Na goal: 135-145

BP goal: goal sbp 140

Thrombophylaxis: subcutaneous heparin

Restraints: None

Lines or Drains: PIV

Foley: None

03/08

Post embolization check.

Seen in ICU.

Awake, alert.

No complaints.

Speech fluent.

MAE to command with 5/5 strength.

Right groin dressing intact. No hematoma. Right CFA pulse 2+

Overnight in ICU.

Continue DAPT/steroids.

Diet, activity, fluids orders written. Foley out after bedrest.

Pt and family updated with results of procedure.

03/09

Neurointerventional Progress Note

Dx: Day one s/p Pipeline/coil embolization of giant left MCA aneurysm

Events: None

S: Mild soreness right upper thigh. O/w no complaints.

Sitting up in bed, tolerating PO

A&0 x 3

Nl speech

MAE

No drift

Right Groin: bruising upper thigh (within confines of pen-marked border). Soft. Right CFA/DP 2+. Feet,toes symmetrically warm with brisk cap refill.

A: Doing well s/p aneurysm embolziaiton

P: To the floor today. Hopeful for home tomorrow.

Will switch to plavix from ticagrelor (order written for Plavix load this after noon)

Pt will go home on Plavix 75mg/day and ASA 325mg/day for 6 months then, likely ASA81mg/day for life.

Continue steroids given adjacent brain edema.

03/09

NEUROCRITICAL CARE PROGRESS NOTE

Brief Patient ID:

32 y/o F w/ PMHx of moderate ETOH use presenting with nausea, vomiting, and multiple syncopal episodes. Head imaging revealed a large unruptured L MCA aneurysm. Transferred to NNN for neurosurgical care. DSA completed on 3/6/22 which showed a 29 mm distal M1 segment left MCA aneurysm. S/p L MCA pipeline embo of giant L MCA aneurysm and now on DAPT.

Events:

3/6 - txf for active but unruptured aneurysm - DSA done

3/7 - NAEO. Remains neurologically intact and on Decadron taper per NSGY.

3/8 - s/p Stent assisted coiling

3/9 - remains stable overnight, NAEO

Subjective:

No headaches.

Objective:

Intake/Output Summary (Last 24 hours) at 3/9/2022 1700

Last data filed at 3/9/2022 1600

Gross over last 24 hours

Intake 1490 ml

Output 350 ml

Net 1140 ml

Neurological Exam:

GCS = E:4 V:5 M:6

Mental Status: Alert and oriented x 3, memory, attention, concentration and language intact.

Sensory: Intact to light touch x 4

Motor: Normal tone and no tremor. Moves all extremities.

Reflexes: Patella and biceps 2+ bilaterally; no clonus. Plantar reflex is downgoing.

Cerebellar: No ataxia on finger-to-nose, heel-knee-shin.

Gait: Not tested due to bedrest

Assessment and Plan:

Active Hospital Problems

Diagnosis

• (Principal) NONRUPTURED CEREBRAL ANEURYSM

• ALCOHOLIC CIRRHOSIS

• METABOLIC ACIDOSIS

• HYPONATREMIA

• LEUKOCYTOSIS

#. Symptomatic unruptured L MCA M1 aneurysm (3 cm wide) without SAH -- Transfer to 9F

-- ASA + Plavix

-- SBP 100-160

-- Na goal - 135-145 (3% stopped and can trial salt tabs to maintain eunatremia)

-- Regular diet. NPO past midnight for tomorrow.

-- Decadron taper per NSGY

-- OK for Sub Q Heparin tomorrow v/s d/c home tomorrow

#. Hx of alcoholism

-- CIWA nursing assessments

-- Thiamine and Folate

#. Tobacco consumption

-- Nicotine replacement

Overall plan after transfer out of intensive care unit:

· Repeat computed tomogram not necessary;

· If stable, disposition location per hospitalist/rehab consultant in AM Thursday (depending on surgical plan) - consult X2641 if questions arise;

· Examination at time of transfer note: see today's progress note

· DVT prophylaxis plan: see today's progress note

· Plan for additional follow-up imaging in future: Depending on NSGY/NIR

03/10

Hospital course reviewed

Brief Patient ID:

32 y/o F w/ PMHx of moderate ETOH use presenting with nausea, vomiting, and multiple syncopal episodes. Head imaging revealed a large unruptured L MCA aneurysm. Transferred to NNN for neurosurgical care. DSA completed on 3/6/22 which showed a 29 mm distal M1 segment left MCA aneurysm. S/p L MCA pipeline embo of giant L MCA aneurysm and now on DAPT.

Events:

3/6 - txf for active but unruptured aneurysm - DSA done

3/7 - NAEO. Remains neurologically intact and on Decadron taper per NSGY.

3/8 - s/p Stent assisted coiling

3/9 - remains stable overnight, NAEO

Events;

3/10- stable

Subjective:

Patient doing ok, no headache

Objective:

Patient Vitals for the past 24 hrs:

Assessment and Plan:

Neuro: Symptomatic unruptured L MCA M1 aneurysm (3 cm wide) without SAH

-- ASA + Plavix

-- SBP 100-160

-- Na goal - 135-145

-- Regular diet.

-- Decadron taper per NIR Dr AAA over 1 week. Ok to dc home

ID; mild leuckocytosis due to steroids

Tobacco consumption, counseled, nicotine patch

Dispo; Dc home

Inpatient Medical Coding

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Sample IP chart 1 Progress Notes

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