Transcript

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<exact dictated text for the clinical notes>
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[TRANSCRIPT]
Doctor: Good morning, Ms. Chen. What brings you in for your follow-up visit today?

Patient: Good morning, Doctor. I'm here for my hypertension medication follow-up, but I've also been having some other problems. My left hand has been hurting very badly, and I've been having some unusual experiences where I see or hear things that aren't really there.

Doctor: Let's go through everything carefully. How long have you been experiencing the left hand pain?

Patient: The pain has been severe. It's been bothering me quite a lot and has also been affecting my sleep.

Doctor: How would you describe the pain?

Patient: It's a very severe pain in my left hand. It feels like there may be something affecting the nerves.

Doctor: Given your cancer history, the pain may be related to cancer involvement of the nerves. We'll need to address your comfort and pain control.

Patient: I've also been having hallucinations. They started after my pain medications were increased.

Doctor: What pain medication are you currently taking?

Patient: I'm taking oxycodone for the pain, and the dose has been relatively high because of how severe the pain has been.

Doctor: The hallucinations may be related to the high-dose opioid use. We need to make some medication adjustments and have you evaluated by palliative care psychiatry.

Patient: Okay. That makes sense.

Doctor: How have you been sleeping?

Patient: I'm having trouble sleeping because of the pain.

Doctor: That may also be contributing to how you're feeling. We'll address the insomnia as part of the treatment plan.

Doctor: Now let's review your blood pressure medications. What are you currently taking?

Patient: I'm taking Lisinopril 10 mg once a day and Hydrochlorothiazide, 12.5 mg once a day.

Doctor: Have you noticed any problems with those medications?

Patient: I've had a persistent dry cough for about three weeks. I've also been getting dizzy intermittently in the mornings.

Doctor: What have your blood pressure readings been at home?

Patient: Usually around 138 to 145 over 85 to 90.

Doctor: Have you had any chest pain, shortness of breath, or palpitations?

Patient: No, I haven't had any chest pain, shortness of breath, or palpitations.

Doctor: Okay. Let's check your vital signs. Your blood pressure today is 142 over 88, your heart rate is 74 beats per minute, your temperature is 98.2 degrees Fahrenheit, and your oxygen saturation is 98 percent.

Patient: Okay.

Doctor: I'll also examine you. Your lungs are clear to auscultation, there is no peripheral edema, and I don't see any orthostatic blood pressure changes.

Patient: That's good.

Doctor: Your hypertension is still somewhat suboptimally controlled on the current regimen. The persistent dry cough is likely related to Lisinopril, which is an ACE inhibitor.

Patient: So should I stop taking Lisinopril?

Doctor: Yes. We'll discontinue Lisinopril 10 mg and transition you to Losartan 50 mg once daily. Losartan is an ARB and should avoid the ACE-inhibitor-related cough.

Patient: Okay.

Doctor: Continue taking Hydrochlorothiazide 12.5 mg once daily.

Patient: I'll continue it.

Doctor: The morning dizziness may be positional and may also be related to some volume depletion from Hydrochlorothiazide. Make sure you stay adequately hydrated and stand up slowly when changing positions.

Patient: Okay, I'll make sure to do that.

Doctor: I'd also like you to have a basic metabolic panel checked so we can monitor your potassium and creatinine after starting the new ARB regimen.

Patient: Sure.

Doctor: In addition to that, because of your severe left hand pain and hallucinations, we're going to adjust your pain and symptom medications.

Patient: What will I be taking?

Doctor: We'll start Gabapentin 300 mg three times daily for the neoplasm-related neuropathic pain.

Patient: Okay.

Doctor: We'll also prescribe Haloperidol 0.5 mg twice daily as needed to help manage the hallucinations and delirium symptoms.

Patient: All right.

Doctor: Your Oxycodone will be adjusted to 5 mg every six hours as needed. Because of the hallucinations and concern for opioid-related effects, we want to avoid unnecessary high opioid dosing while still keeping your pain under control.

Patient: I understand.

Doctor: I'm also placing an urgent referral to palliative care psychiatry for evaluation of the hallucinations and assistance with managing your cancer-related neuropathic pain and medications.

Patient: I think that would be helpful.

Doctor: We'll obtain laboratory testing as well. The orders include a Comprehensive Metabolic Panel, or CMP, CPT 80053, associated with your neoplasm-related pain; a Complete Blood Count, or CBC, CPT 85025, associated with your malignant neoplasm; and a serum opioid level, CPT 80361, which will be performed STAT because of the concern for opioid-related delirium.

Patient: Okay.

Doctor: Your referral will be to Palliative Care Psychiatry with urgent priority. The referral is for opioid-induced hallucinations and psychiatric evaluation for cancer-related neuropathic pain management.

Patient: Understood.

Doctor: We'll also document the diagnoses associated with today's visit. The primary diagnosis is neoplasm-related pain, acute or chronic, G89.3.

Patient: Okay.

Doctor: The secondary diagnoses include delirium due to a known physiological condition, F05; malignant neoplasm, unspecified, C80.1; and insomnia, unspecified, G47.00.

Patient: All right.

Doctor: For the office visit, the procedure code is 99214 for an established patient office or outpatient visit with moderate complexity, 30 to 39 minutes, with modifier 25. We'll also document CPT 90837 for psychotherapy, 60 minutes with the patient, and CPT 99000 for handling and conveyance of the laboratory specimen.

Patient: Okay.

Doctor: Based on those CPT codes, the estimated billing total is $349, subject to payer adjudication.

Patient: Understood.

Doctor: I want you to monitor your blood pressure at home after switching from Lisinopril to Losartan. We'll repeat your blood pressure check in four weeks.

Patient: Okay.

Doctor: Because of the pain, hallucinations, and medication changes, I also want you to follow up with me in two weeks so we can assess how effective the new medications are and make sure you're comfortable.

Patient: I'll come back in two weeks.

Doctor: Please remember to stay adequately hydrated, change positions slowly, and take your medications exactly as prescribed. We discussed the reason for changing Lisinopril to Losartan, as well as the reason for adjusting your pain medications.

Patient: I understand.

Doctor: If the hallucinations become significantly worse, your pain becomes uncontrolled, or you develop any concerning symptoms, seek medical attention promptly.

Patient: I will. Thank you, Doctor.

Doctor: You're welcome, Ms. Chen. We'll see you in two weeks for your symptom and medication follow-up, and we'll repeat your blood pressure check in four weeks.