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CLINICAL EXAMPLE 99231
 

 

A post-op hip surgery patient with stable hypertension and osteoarthritis

CC: Follow-up hip replacement and hypertension

Interval History: Patient states his right hip pain has improved.  No new complaints.

Physical Exam
General appearance: No acute distress; conversant
Vitals: 98.6, 72, 20, 110/74
Lungs: CTA
CV: RRR

Labs: None today

Assessment

  1. Osteoarthritis, POD #3 right hip replacement
  2. Well controlled hypertension


Plan

  1. PT/OT
  2. Continue BP meds
  3. Continue routine anticoagulation therapy

For a detailed breakdown of this note with tips and advice see    99231 E/M Insight

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