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CLINICAL EXAMPLE 99204
 

 
A patient with stable hypertension and diabetes

CC : “ I need a primary physician.”

HPI :The patient is a pleasant 71 year old gentleman who presents to establish care with a local physician after relocating to this area.  He has a history of hypertension and diabetes, both of which have been fairly easy to control with routine medications.  He also reports a history of coronary artery disease, which has been quiescent over the past two to three years following PTCA and stent deployment.  He has no spontaneous somatic complaints.

Medications

Atenolol 25 mg PO QD
Glyburide 5 mg PO BID
Lisinopril 10 mg PO BID
Atorvastatin 20 mg PO QD

PMH : per HPI, plus osteoarthritis and dyslipidemia

ROS :Complete ROS was performed and documented and was positive for intermittent lower extremity edema and easy bruising.  For more details, please refer o the ROS questionnaire with today’s date located in the chart.

FH : Mother died in her 80s of “old age”; father at age 72 of pneumonia.  The patient has three grown children in good health.
 
SH : The patient has been married for 45 years.  He denies tobacco or alcohol abuse and continues to drive himself around.

Physical Exam

Vitals: 130/80, 88, 98.6
General appearance: NAD, conversant
Eyes: anicteric sclerae, moist conjunctiva; no lid-lag; PERRLA
HEENT: AT/NC; oropharynx clear with MMM and no mucosal  ulcerations;auditory canals patent with pearly TMs
normal hard and soft palate Neck: Trachea midline; FROM, supple, no thyromegaly or lymphadenopathy
Lungs: CTA, with normal respiratory effort and no intercostal retractions
CV: RRR, no MRGs
Abdomen: Soft, non-tender; no masses or HSM
Extremities: No peripheral edema or extremity lymphadenopathy
Skin: Normal temperature, turgor and texture; no rash, ulcers or nodules
Psych: Appropriate affect, alert and oriented to person, place and time

Labs: HGBA1c 6.8; BUN 25, creatinine 0.8; LDL 88, HGB 12

Assessment

  1. Well controlled essential hypertension
  2. Optimally controlled NIRDM
  3. Stable dyslipidemia
  4. Stable CAD
Plan
  1. Continue current medications unchanged
  2. Return visit in three months
  3. Will check repeat HGBA1c, CBC, and renal profile
  4. Will also check LFTs since patient is on statin medication
  5. Will also check spot microalbumin/creatinine


For a detailed breakdown of this note with tips and advice see   99204 E/M Insight

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