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Patient: Marissa Mountaine Date of Birth: 05/05/19xx Date of Service: 10/22/20xx History: This is a female patient with no primary care physician who pres- ents to hospital with a chief complaint of vomiting for the last 4 days, abdominal pain, back pain, urinary frequency, and dysuria. History of Present Illness: The patient states that, 4 days ago, she started off Thursday with stomach pressure. She promptly vomited. Patient cannot hold much food or liquid down. The abdominal pain at first was moderate, became severe over the last several days. She developed a headache as well and got muscle aches as well as bilateral back pain. She states that she had some dysuria on Thursday but it was mild to moderate, but now it has worsened gradually over the last 4 days. Past Medical History: Fairly unimpressive. She has had two cesarean sec- tions for twins and one child, so she has three children. They are all healthy. She got hit by a car when she was 12 and had open reduction, apparently, of her left radius and right ankle. Other than that, she states she really is fairly boring as far as past medical history. Family History: Positive in two female relatives for diabetes mellitus, her grandmothers on both sides of the family. Social History: She does not smoke, drink alcohol, or take recreational drugs. Medications: She has no current medications, including over-the-counter health food type medications, etc. Allergies: She was told long ago that she was allergic to ibuprofen and aspirin. Vaccination Status: She is unsure. Examination: Lungs: Clear on auscultation and percussion. No rales, rhonchi, wheezes. No dullness or tympanism. Heart: S1 and S2 regular. No audible murmur, gallop, or rub. The point of maximal impulse is nondisplaced. Breasts/pelvic/rectal: Not performed at present. This will be left in fol- low-up as outpatient, either with me or someone else. Abdomen: Positive tenderness, most pronounced in the hypogastric area. No rebound, rigidity, or guarding. Bowel sounds positive in all 4 quadrants. No organomegaly or masses. Positive bilateral costovertebral angle tenderness on mild to moderate percussion. Extremities: Negative Homan’s sign, negative edema, cyanosis, or club- bing of the upper and lower extremities. Pedal pulses are palpable, as are popliteals, radials, ulnars, and brachials. Skin: No plaque, scaling, vesicular eruptions, or rashes. Turgor appears somewhat decreased. Neurologic: Alert and oriented ×3. Cranial nerves 2-12 intact. No motor deficits found. No pathological reflexes on exam. Musculoskeletal: Mild tenderness on palpation of paravertebral muscles, deltoids, quadriceps, and calf muscles, but nothing severe. Endocrine: Negative central obesity. Negative buffalo hump, moon facies, exophthalmus, or thyromegaly. Hematological/lymphatic: Negative petechiae, purpura, or ecchymosis. Negative cervical or axillary or inguinal lymphadenopathy. Negative splenomegaly. Psychiatric: No undue signs of anxiety, depression, suicidal ideation, or psychotic behavior on interview. Studies Done to Date: Her EKG shows sinus tachycardia, nonspecific ST-T changes throughout. Her basic metabolic panel: blood sugar 88, BUN 12, creatinine 0.8, sodium 135, potassium 3.5, chloride 96, bicarb slightly low at 20, calcium 9.4. Her CBC shows a white count of 23,000. Hemoglobin normal at 15. Platelets 241. There is a left shift in the differential Magnesium normal. Pregnancy test is negative. Urinalysis is significant for positive nitrites, moderate blood, large leukocyte esterase, many WBCs, 2 bacteria. Assessment: 1. Acute pyelonephritis. 2. Nausea and vomiting that was intractable on admission. 3. Hypokalemia secondary to nausea and vomiting. Plan: Admit as inpatient. Replace her potassium. Replace her IV fluids as I believe she is also clinically dehydrated. Give her IV Cipro. We have cultures cooking, both of blood and urine. Hopefully these will give us some answers so we can be specific in our treatment, but Cipro is a good choice. I will give her antiemetics and narcotics for pain control, mostly in the muscular areas, with oral medication. The patient should do well, as I believe she is very healthy otherwise. Jeffery Family, MD Charge Ticket Patient Name Medical Record Number/Account Number Physician Practice Name Insurance Company Date of Birth Marissa Mountaine 127766 Jeffrey Family, MD Compliance Medical Group Healthnet Insurance 05/05/19xx Date of Service Place of Service CPT Code Diagnosis Code(s) Modifier Quantity Fee 10/22/20xx 21 99222 N11.0 E87.6 1 135.00 1) Choose a MDM Level (straightforward, low, moderate, or high) 2) Choose an E/M code as applicable. 3) List any other applicable billable services (CPT code(s)) 4) List any and all Diagnosis code(s) 5) Make a decision – Is the charge ticket accurate per your audit? Why? Why not?

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