Hematology Established Office Visit #1

Hematology Established Office Visit #1

REASON FOR THE VISIT (Chief Complaint): Followup on myeloproliferative disorder/essential thrombocythemia.

HISTORY (History of Present Illness HPI): Mr. White is an 82 yr. old gentleman with multiple medical comorbidities and persistent (Timing) thrombocytosis, and was recently diagnosed with myeloproliferative disorder/essential thrombocythemia through the bone marrow biopsy, which showed hypercellular bone marrow with increased megakarycytes in clusters with atypia (MDM Data Review- Review old Records). Due to the concern of his chronic (Severity) nonhealing (Quality) ulcer at the left lower extremity (Location) and the side effect (Context)profile of hydroxyurea with potential skin ulcer formation, he was initially managed with anagrelide(Modifying Factor). His platelet count was poorly controlled with low-dose anagrelide and he tolerated the increased dose poorly with significant dizziness (Assoc Signs & Symp or Neuro ROS). Therefore, at the previous visit, we had started him with hydroxyurea with instruction of monitoring the status of the chronic ulcer. The hydroxyurea and anagrelide both were discontinued on April 25, 2007, when his platelet count dropped to 208,000 (Severity), and he returned to clinic today for a scheduled followup and possibly to start low-dose Hydrea if the count increase again. Symptomatically, Mr. White’s general condition has been unchanged. He is still bothered with his nonhealing ulcer at the left lower extremity, which has been for 20 to 30 years (Duration). He has been changing the dressing by himself (Modifying Factor), but he denied change in the size of the ulcer or any abnormal discharge. He still has a little bit trouble (Context) with his prosthesis for the right BKA. Otherwise, he has no symptoms to report.

No fever, night sweats, weight loss, or other constitutional symptoms (ROS Const). No dizziness, lightheadedness (ROS Neuro), vision changes (ROS Eye), abnormal sensation, or focal weakness. No fatigue, chest pain or pressure, palpitation (ROS Card), or exertional shortness of breath (ROS Resp). No cough, hemoptysis, or pleuritic chest pain.

No bruises, hematuria, or any other kind of bleeding (ROS Hem). No anorexia, nausea, early satiety, or bowel habit change (ROS GI).

PAIN: Discomfort at the right lower extremity (ROS MS) where prosthesis is attached.

Otherwise, he has no pain. PAST MEDICAL HISTORY: (Past Medical HX)

1. Severe peripheral vascular disease, status post right BKA for gangrene of the right foot. 2. Chronic ulcer at the medial aspect of the left ankle with history of frequent infection. 3. MPD/essential thrombocythemia. MEDICATIONS: Aspirin 81 mg. He has been off anagrelide and hydroxyurea since April 25, 2007. (Past HX)

REVIEW OF SYSTEMS: A 12-point system review revealed unchanged discomfort at the right lower extremity with prosthesis and chronic ulceration at the left ankle. (Counts only for MS. 12 point = does not count for a complete ROS per CMS DG)

HISTORY: HPI = 4+ ROS = 8 systems PFSH = 1 area

Extended HPI + Extended ROS + Pertinent PFSH = Detailed History

PHYSICAL EXAMINATION:

95=Blue 97(Hem/Lymph)=Red

(CONSTITUTIONAL) General: Looks well, not in acute distress. Temperature: 97. Blood pressure: 170/84. Pulse: 86. Respirations rate: 20. (2 bullets for appearance and vitals)

HEENT: No alopecia. (INTEGUMENTARY) No icterus sclerae. No conjunctival pallor or hemorrhage. (EYE) Oral cavity: Clear with no lesions (ENT). (1 Insp of conj, 1 insp skin, 1 insp oral mucosa)

Neck: No JVD (CARDIOVASCULAR). No palpable lymphadenopathy (HEM/LYMPH). (1 insp neck, 1 palp lymph nodes)

Lungs: Clear to auscultation (RESPIRATORY). (1 ausc lungs)

Cardiovascular: Regular rate and rhythm (CARDIOVASCULAR). (1 ausc heart)

Abdomen: Soft, nontender. No palpable spleen (GASTROINTESTINAL). (1 exam abd)

Extremities: No swelling (CV). No bruises (HEM/LYMPH). No lesions at right BKA stump (INTEGUMENTARY). The left lower extremity ulcer was not examined, which has been well dressed. ( 1 CV palp for edema) ( 1 bullet already given above for insp skin)

Neurological exam: No focal deficit (NEUROLOGICAL). (not spec enough for 97, no bullet describes)

EXAMINATION: 1995 = 8 Systems COMPREHENSIVE (this exam is better in this instance)

EXAMINATION: 1997 Hem/Lymph exam = 10 bullets EXPANDED PROBLEM FOCUSED

LABORATORY DATA: CBC today, WBC 9.6, hemoglobin 12.9, hematocrit 38.0, platelets 840, and ANC 5.47. (MDM DATA REVIEW = 1 POINT)

IMPRESSION: An 82 yr. old gentleman with history of persistent erythrocytosis secondary to chronic infection and myeloproliferative disorder/essential thrombocythemia. His platelet count was eventually controlled with hydroxyurea.

However, with concern of bone marrow suppression leading to thrombocytopenia,

the hydroxyurea 500 mg b.i.d. was discontinued two weeks ago when his platelet dropped to 208,000. At this time, the stat CBC showed moderately elevated platelet count, and it is quite possible the thrombocytosis will progress if he is not put on any cytoreductive treatmen at this time. Therefore, we have decided to restart hydroxurea at a lower dose, 500 mg daily, and titrate according to CBC. The potential side effects of hydroxyurea including bone marrow suppression with potential anemia and leukopenia, and skin ulceration, particularly in his case were again discussed. The patient expressed willingness to have close monitoring of his skin ulcer and inform me if there is any change, so the medication can be adjusted. He also knows to call if he develops fever, sore throat, or any other kind of infection.

PLAN:

1.  Start Hydrea 500 mg daily.

2.  Continue to hold off on anagrelide due to its poor control of platelet count and the patient’s poor tolerance with dose escalation.

3.  The patient was given a slip to have CBC monitored at local office on weekly basis and I will contact the patient for dose adjustment based on the result.

4.  Office visit in one month.

(MDM: # diagnosis or management options: One established problem, worsening. 2 points)

(MDM: Data Review: review labs: 1 point)

(MDM: Risk: High: Drug therapy requiring intensive monitoring)

Overall MDM Level: Low

Detailed History + Comprehensive Exam + Low MDM = 99214

ICD-9 coding:

1. Myeloproliferative Disorder 238.79

2. Essential Thrombocythemia 238.71