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CLINICAL EXAMPLE 99213
 

 
An established office patient with osteoarthritis

CC : “ knee pain.”

Interval History : Patient with known osteoarthritis which had been previously controlled on Tylenol.  Now states his left knee has been aching for about two weeks despite two to three doses of Tylenol per day.

ROS :  Musculoskeletal--Negative for arthralgias or worsening joint pain elsewhere

Physical Exam

Mild swelling of left knee compared to the right.  Some pain with passive rotation.  No overlying warmth or erythema.

Assessment

  1. Worsening osteoarthritis
Plan
  1. Start OTC ibuprofen 400 mg po TID, PRN
  2. Return visit in two weeks if no improvement
For a detailed breakdown of this note with tips and advice see    99213 E/M Insight
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