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CLINICAL EXAMPLE 99214
 

 
An established office patient with hypertension, diabetes and a history of dyslipidemia

CC : Follow-up hypertension and diabetes

Interval History : The patient’s hypertension has been well controlled on current medications.  Diabetes is stable as well, with no significant hyperglycemia or episodes of symptomatic hypoglycemia.  Dyslipidemia remains well controlled on statin therapy.

Medications

Lisinopril 20 mg po qd
Atorvastatin 10 mg po qd
Glyburide 10 mg po bid

ROS
General - Negative for fatigue, weight loss, anorexia
Cardiovascular - Negative for chest pain, orthopnea or PND
Neurologic - Negative for paresthesias

Pertinent PFSH is remarkable for mild OA which has been quiescent

Physical Exam
General: NAD, conversant
Vitals: 120/80, 65, 98.6
HEENT: No JVD or carotid bruits
Lungs: CTA
CV: RRR
Extremities: No peripheral edema

Labs: BUN 12, creatinine 0.8, HGBA1C 6.8, spot microalbumin/creatinine ration is 28 mcg/g; LDL 77

Assessment
    1. Well controlled Type 2 NIRDM
    2. Well controlled hypertension
    3. Stable dyslipidemia

    Plan


    1. Continue current medications unchanged
    2. Repeat renal profile, spot microalbumin/creatinine at next visit, along with cbc
    3. Check LFTs at next visit as well due to ongoing statin therapy
    4. Continue lifestyle modifications and exercise for weight loss
    5. Return visit in four months

    For a detailed breakdown of this note with tips and advice see   99214 E/M Insight

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