Emergency and Outpatient Record

CASE 6-10A

Emergency and Outpatient Record

The following reports are for a 50-year-old white male who is seen in the emergency department of the local hospital. The patient was first seen in the emergency department by the physician on staff. The emergency department physician then turned the case over to Dr. Elhart, the cardiologist from the local clinic who was on call. Dr. Elhart admitted the patient to the hospital. Code the emergency outpatient services provided to the patient by Dr. Sutton.

LOCATION: Outpatient, Hospital

PATIENT: Kenneth Peters

PHYSICIAN: Paul Sutton, MD

SUBJECTIVE: This is a 50-year-old white male who has a history of hypertension. He has no other significant ongoing medical problems and takes no other medications. He is on aspirin and nifedipine. He has no known allergies. He presents acutely to the emergency room today with a history of suddenly developing substernal chest pressure radiating to his jaw that started about 1 hour prior to his arrival. He had diaphoresis and some nausea associated with this. He had no significant dyspnea, however. Other than his history of hypertension and remote smoking history when he quit smoking about 23 years ago, he has no significant risk factors for coronary artery disease.