Asymptomatic Hypertension – MedTx, LLC 2017

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  • CC: year old with pertinent PMH/PSH presents with
  • HPI (focused):
    • any recent chest pain,
    • SOB,
    • acute headache/slurred speech, ataxia, limb weakness, facial droop, changes in vision.
    • blood in urine.
  • ((+))
    • Re-evaluation:
      • Improved on re-evaluation.
        • On thorough re-evaluation, after patient was observed on telemetric monitoring, patient remains hemodynamically stable, normal vital signs, with clear sensorium, repeat cardio-pulmonary-abdominal exam benign, is ambulatory, has no new development of pain, pain is well-controlled and is amenable to discharge after observation period in the ED.
        • Neurologically Intact.
          • Patient has normal speech, clear sensorium, exhibits linear thinking, able to articulate plan for aftercare, and exhibits normal fine motor skills.
          • Abdominal Benign. Repeat abdominal exam did not reveal any tenderness in any of the four quadrants. No rebound their guarding. patient tolerated PO fluids and food to the emergency department without any recurrence of abdominal pain or vomiting.
        • Respiratory status
          • No signs of respiratory distress on exam, able to speak in full sentences without dyspnea. Respiratory related vital signs reassuring and suggestive of improvement. Improved respiratory exam compared to prior.
          • Unchanged respiratory status compared to prior.
          • Worsening respiratory status compared to prior.
        • Clinically Sober.
          • Patient demonstrates clinical sobriety.
            • speak non-slurred speech
            • is alert and oriented
            • ambulatory with steady gate
            • has fine motor intact
            • able to articulate plan for safe aftercare upon discharge from ED.
          • Re-evaluation after sobriety did not reveal any new symptoms/signs. Unlikely initially unappreciated pathology on initial eval given patient has no new complaints and re-examination does not reveal any new abnormalities suggestive of previously undetected pathology.
          • Instructed patient to exercise cautions after discharge
          • Patient requests discharge, will oblige demonstration of capacity, sobriety, and no unevaluated pathology.
      • On re-evaluation, remains intoxicated. Hemodynamically stable. Will continue observation.
    • Diposition:
      • home.
        • Counseled patient on assessment, impression, plan.
          • Discussed disposition options with patient after counseling as above and included option for continued observation in medical setting however shared decision making yielded joint decision for disposition to home with self and family observation, prompt follow up with PCP, and return to ED precautions. Counseled patient on complaint specific return precautions given that there are pathologies that, while sufficiently unlikely to warrant further investigation at this time, may develop/worsen after discharge. Counseled that early in a disease progress, a work up can be falsely non-revealing of more significant pathology however this does not exclude the possibility of developing serious pathology thereby underscoring the importance of prompt follow-up with PMD and low threshold for return to ED as needed.
      • Observation
        • Indication:
      • Admitted,
        • transfer of care kindly assumed by admitting team
        • at
        • level of care,
        • with service.
      • Sign out at change of shift, transition of care kindly assumed by oncoming ED team
        • to
        • pending
        • at
    • Additional documentation:
      • DIAGNOSIS:
        • ((Of note, to bill for critical care time, the primary diagnosis must be one of the diagnoses below))
        • ICD-10 code:
      • OBSERVATION NOTE:
        • Total observation time
        • Start of observation time
        • End of observation time
        • Decision for disposition made after observation. Disposition to
        • Observation performed in order to attempt to safely preclude an inpatient admission.
        • Observation was performed given
          • diagnostic uncertainty (i.e. serial examinations and assessments by me to elucidate likelihood of a pathologic process).
          • to determine intensity therapy required (i.e. there was a reasonable possibility that by observing the patient's response to therapy, an admission may be abated and safely discharged).
        • Observation by me in ED.
        • The observation was utilized as the primary diagnostic tool during that time.
        • Of note, additional history was obtained at this time and there was no family history contributory to the patient's current condition.
        • Given patient had initial complaint concerning for significant deterioration resulting in severe morbidity and potential mortality, patient required direct observation and monitoring in the emergency department with trending of vital signs, telemetric monitoring reviewed by me, frequent reassessments by nursing with communication with me of status, re-accessments in addition by me, which were all required for patient's safety during that time (monitoring while administering medications with risk for CNS/cardiac/pulmonary adverse reactions) and to determine patient's disposition by assessing for response to interventions/treatment. Patient was observed under my supervision.
        • Revenue code: 0762. HCPCS Code G0378
      • CRITICAL CARE PROCEDURE NOTE:
        • Authorized and performed by: Attending physician
        • Total critical time:
          • minutes.
        • Indication for critical care including pt has exhibited risk factors for and symptoms and signs concerning for impending deterioration included compromise of
            • airway,
            • respiratory stability,
            • cardiovascular collapse,
            • CNS irreversible damage,
            • metabolic derangements
            • renal failure
            • fulminant hepatic failure
        • PRIMARY DIAGNOSIS:
          • ((primary diagnosis must be one of these for critical care time to be documented))
        • Due to patient having a presentation that is concerning for a potentially pathologic process causing an resulting in significant morbidity and potential mortality, the patient required emergent evaluation in the emergency department including emergent diagnostics, emergent assessment and evaluation, and emergent and directed treatment in order to mitigate risk for life-threatening deterioration. The critical care time as indicated above included discussing history with patient, examining patient, interpreting vital signs including pulse oximetry, initiating and interpreting diagnostics, and clinical acumen in order to synthesize patient's presentation to develop treatment plan and emergently implement the requisite steps. This part of my care the patient is exclusive of other billable procedures, specifically procedures, treating other patients, and any educational time. Please refer to the above rationale for further documentation regarding the critical nature of the patient during my care.
        • This critical care time is separate from teaching or other separately billable procedures or treating other patients.
      • COUNSELING:
        • Patient/family educated to the extent possible in terminology matched to their understanding on diagnostics, assessment, and treatment plan along with the risks inherent to the diagnostics and therapeutics and plan. Patient/family amendable and in agreement with above plan. All questions and concerns addressed and answered.
        • Attempted shared decision making in discussion with patient/family in all circumstances where feasible and possible.
        • Attempted to explain and obtain patient's approval for plan however unable to do so secondary to patient's condition and the requirement of emergent evaluation and interventions.
      • SUPERVISION: Discussed and obtained approval/confirmation of evaluation (history, exam, diagnostics) and plan (assessment, interventions, disposition) with ED attending physician
      • Of note, follow up over-read mechanism in place for over-reads and follow up of pending diagnostics.
  • Assessment/Plan:
    • year old with PMH/PSH of presents with
  • suspected to have asymptomatic elevated blood pressure
  • DDx includes but in not limited to (pt does not meet reasonable likelihood/consistency with the dx to warrant additional pursuit of these entities (risks outweigh benefits of non-indicating testing)
    • symptomatic hypertension,
    • hypertensive encephalopathy,
    • hypertensive nephropathy,
    • hypertensive urgency,
    • hypertensive emergency,
  • Plan:
    • Advised for outpatient follow up. Anti-hypertensives deferred until pt establishes PCP.
      • Pt does not have any symptoms on history nor signs on physical exam concerning for end organ damage secondary to hypertension. Per ACEP Clinical Policies, routine screening for end organ damage in the ED is not indicated and would expose patient to prolonged ED stay without likely benefit given patient requires management from primary care physician who can follow labs, provide continued evaluation as opposed to emergency department evaluation which may need to be repeated by primary care doctor.
        • Specifically, based up the patient’s presentation, the patient is at sufficiently low risk for:
          • (cardiac) ACS given no CP, no SOB, normal cardio-pulmonary exam
          • (neurologic) – SAH/stroke given no hx of acute headache/slurred speech, ataxia, limb weakness, facial droop, changes in vision and normal neurologic exam.
          • (renal) – end organ renal disease given no hematuria
        • Outpatient anti-hypertensive medications were deferred at this time given risks of adverse events/benefits of initiating anti-hypertensive medication without continued monitoring (not feasible in Emergency Department setting). This is in accordance with ACEP clinical guidelines.
    • Basic laboratory evaluation conducted . Anti-hypertensives deferred until pt establishes PCP.
      • Laboratory analysis which was non-revealing of any pathology requiring emergent interventions. The patient was informed that this does not suggest that the elevated is not harmful to health and still requires management of elevated blood pressure on an outpatient basis.
      • Specifically, based up the patient’s presentation, the patient is at sufficiently low risk for:
        • (cardiac) ACS given no CP, no SOB, normal cardio-pulmonary exam,
        • (neurologic) – SAH/stroke given no hx of acute headache/slurred speech, ataxia, limb weakness, facial droop, changes in vision and normal neurologic exam.
        • (renal) – end organ renal disease given no hematuria
    • Advised for outpatient follow up. Per patient request, anti-hypertensive was initiated.
      • amlodipine 5mg daily short course given attempt to utilize medication which would require least monitoring until patient can establish definitive care by primary care physician. Pt assures me will follow up with PCP.
      • lisinopril 5mg daily short course given no evidence of renal failure on basic labs and patient assures will follow up with PCP.
      • HCTZ 25 mg daily short course. Patient assures will follow up with PCP.
      • Patient cautioned on risks of initiating anti-hypertenisves and risk for pre-syncopal or syncopal event. As such, advised to refrain from driving, placing body at places for fall risk, exercising extreme caution when standing, and explained risks of orthostatics. Patient still desires anti-hypertesnive to be initiated now which is not unreasonable given patient demonstrates capacity to make this decision, agrees to exercise caution, and to follow up promptly with PCP.
  • Counseling:
    • The patient was counseled regarding the deleterious long term effects of hypertension and the necessity of follow up with primary care to establish a care plan. The patient was provided with information for primary care providers in the event the patient is not able to obtain prompt follow up. The patient understands that at this time there is no evidence for a more malignant underlying process, but the patient also understands that early in the process of an illness, an initial workup can be falsely reassuring. Routine discharge counseling was given to the patient and the patient understands that worsening, changing or persistent symptoms should prompt an immediate return for reevaluation. The importance of appropriate follow up was also discussed with the patient. More extensive discharge instructions were given in the patient’s discharge paperwork. Patient expressed understanding of plan, was amenable to plan. All questions answered.
  • Dipso: Home with PMD follow up.