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WINTER HILLS CARDIOLOGY 420 VENTURA BYPASS • CENTRAL, FL 32811 • 407-555-4798 PATIENT: WALLACE, LEO ACCOUNT/EHR #: WALLLE001 Primary Care Physician: Quentin David, MD Attending Physician: Martina Cataleone, MD Presenting Complaint/Chief Complaint: Right leg DVT HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old male patient, presenting to my office today with a 4-day history of right leg discomfort and swelling. Patient also complaining of hematuria and smelly urine with no fever or chills nor dysuria. Patient was sent to have an urgent venous Doppler as he was found on clinical exam to have varicose veins with right calf tenderness and right leg edema. The urgent venous Doppler results were called to me, which is positive for acute right leg DVT. Patient’s urinalysis is also positive for blood and urinary tract infection. PAST MEDICAL HISTORY: Parkinson’s disease. Patient stated he had DVT 10 years ago in the left leg, for which he was treated only with aspirin. He denies any past medical history of urinary tract infection or renal stones. ALLERGIES: None MEDICATIONS: Sinemet, dose unknown, which he is taking three times a day. He is also on Eldepryl 5 mg p.o. daily. SOCIAL HISTORY: Lives alone. He is a widower for 6 years. Does not smoke. FAMILY HISTORY: REVIEW OF SYSTEMS: Denies any fever. No flank pain, no suprapubic pain, no vomiting, no headache, no shortness of breath, no palpitations. PHYSICAL EXAMINATION GENERAL APPEARANCE: He is comfortable. VITAL SIGNS: His vitals are stable. He is afebrile. Pulse is 80 beats per minute, BP 122/90. HEENT: Unremarkable NECK: Supple. No goiter. No carotid bruits. LUNGS: Clear bilaterally ABDOMEN: Soft. No suprapubic or costovertebral angle tenderness. EXTREMITIES: Examination of his lower extremities reveals bilateral varicose veins. Right calf tenderness is present, as well as right leg edema. NEUROLOGIC: Neurologic exam reveals Parkinsonian tremors with increased rigidity. PELVIC/RECTAL: LABORATORY DATA: Urinalysis, which was done in the office, is positive for blood, nitrate, and also leukocytes. Venous Doppler, as I mentioned above, is positive for acute DVT, right leg. ASSESSMENT: Acute DVT, right distal leg Urinary tract infection Parkinson’s disease PLAN: Patient will be admitted to the Mason Hospital for anticoagulation therapy. We will also get routine blood tests, including CBC, chest x-ray, EKG, INR/prothrombin time. Patient will be started on Coumadin. He is also started on Levaquin. We will get sonogram of his kidneys and bladder to rule out any underlying renal pathology for current urinary tract infection. Patient will be managed by Winter Hills Cardiology. Martina Cataleone, MD Be sure to list the codes, one code per box, in the correct sequence, from top to bottom, and in the proper row. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices. Please list modifiers with the code they relate to as necessary. Include a hyphen in between the code and the modifier. Example Procedure: 43846-74 or for Anesthesia: 00797-P2.

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