Nursing Homework week 10

Reason for Visit: Follow-up after hospitalization for heart failure exacerbation Chief Complaint: "I just got out of the hospital after my heart problem got worse." Type of H & P: Comprehensive Type of Decision-Making: Moderate complexity

Diagnosis (ICD-10):

· I38 — Endocarditis, valve unspecified

· I50.9 — Heart failure, unspecified

· Z09 — Follow-up examination after completed treatment

CPT® Codes:

· 99214 — Established patient, moderate complexity

· 93000 — Electrocardiogram, routine with interpretation/report

Clinical Notes: Patient recently discharged after hospitalization due to acute exacerbation of valvular heart disease with CHF symptoms. Currently stable, denies chest pain, minimal fatigue, mild ankle edema. Reinforced medication adherence (beta-blocker, diuretic), low-sodium diet, daily weight monitoring, and follow-up with cardiology in two weeks.

Social Problems Addressed:

· Medication management

· Nutrition/Exercise

· Knowledge deficit

Skills:

· Physical Assessment (Performed)

· General Skills (Performed)