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CLINICAL EXAMPLE 99205
 

 
A Patient with a history of CHF who presents with shortness of breath

CC : “ Shortness of breath.”

HPI :Patient is a 68 year old male with a history of CHF who presents with SOB. He states this problem began about two weeks ago. The shortness of breath may occur at rest or with exertion. The timing is described as intermittent. His breathing is worse when laying flat. He has noticed his shortness of breath is often associated with worsening lower extremity swelling. He states he has a history of heart disease, but had a “negative” nuclear stress test approximately one year ago.

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. Significant shortness of breath
  2. Well controlled HTN
  3. Optimally controlled NIRDM
  4. Stable dyslipidemia
  5. Stable CAD
Plan
  1. Will add Lasix 40 mg PO qd
  2. Will contact his former physician to obtain records of recent stress test
  3. Will check a CXR today to rule out pneumonia
  4. Will order an ECHO as well to quantify his EF
  5. Return visit next week
  6. Will check repeat HGBA1c, CBC, and renal profile
  7. Will also check LFTs since patient is on statin medication
  8. Will also check spot microalbumin/creatinine


For a detailed breakdown of this note with tips and advice see 99205 E/M Insight

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