pclaybaugh
Networker
Thanks in advance for any answers.
Patient is seen for back pain due to a fall, injected with Toradol. The diagnosis codes are clear but only used one diagnosis code. I am inclined to suggest the provider also add the Dx codes that were addressed (bold font). Happy to accept any input.
The HPI reads as follows:
This patient is a very pleasant 61 y/o F w/ PMH of HTN, HLD, psoriasis, pituitary adenoma s/p resection here today due to an acute complaint of back pain after a GLF on ice two days ago. On Saturday night she was walking outside, slipped on the ice, and landed flat on her back without striking her head. Since then she has had pain all over in her back, worst at the right lower back. She can lay down and walk without issue but the act of sitting/standing up are most painful for her. She has no lower extremity weakness/paresthesias or incontinence. She is taking Advil for the pain.
The provider also notes the following in the assessment and plan:
Encounter for screening for other disorder
#HTN: Consistently meeting goal of <130/80 on telmisartan 80mg, amlodipine 10mg, HCTZ 25mg.
#HLD: LDL is above goal at 120, ASCVD risk is 5.3%. Patient recommended to start a low intensity statin and recheck in 3 months. However, she elected to hold on this and recheck lipid panel in 6 months which is reasonable. Check lipid panel after September of this year.
#Subclinical hypothyroidism: No symptoms, no indication to start levothyroxine
#Chronic sinusitis: Patient reports some improvement with Flonase, but did not start Zyrtec. Advised to start that and continue the Flonase as well.
#Pituitary adenoma: recently seen by neurosurgery, recommended repeat imaging in two years (due 10/25).
#Health maintenance: Colonoscopy - review records, but reportedly had benign colonoscopy in 2022. Mammogram - R sided mammogram benign this month, repeat 3/25. S/p hysterectomy. DEXA age 65. Imms: not addressed this appointment
Patient is seen for back pain due to a fall, injected with Toradol. The diagnosis codes are clear but only used one diagnosis code. I am inclined to suggest the provider also add the Dx codes that were addressed (bold font). Happy to accept any input.
The HPI reads as follows:
This patient is a very pleasant 61 y/o F w/ PMH of HTN, HLD, psoriasis, pituitary adenoma s/p resection here today due to an acute complaint of back pain after a GLF on ice two days ago. On Saturday night she was walking outside, slipped on the ice, and landed flat on her back without striking her head. Since then she has had pain all over in her back, worst at the right lower back. She can lay down and walk without issue but the act of sitting/standing up are most painful for her. She has no lower extremity weakness/paresthesias or incontinence. She is taking Advil for the pain.
The provider also notes the following in the assessment and plan:
Encounter for screening for other disorder
#HTN: Consistently meeting goal of <130/80 on telmisartan 80mg, amlodipine 10mg, HCTZ 25mg.
#HLD: LDL is above goal at 120, ASCVD risk is 5.3%. Patient recommended to start a low intensity statin and recheck in 3 months. However, she elected to hold on this and recheck lipid panel in 6 months which is reasonable. Check lipid panel after September of this year.
#Subclinical hypothyroidism: No symptoms, no indication to start levothyroxine
#Chronic sinusitis: Patient reports some improvement with Flonase, but did not start Zyrtec. Advised to start that and continue the Flonase as well.
#Pituitary adenoma: recently seen by neurosurgery, recommended repeat imaging in two years (due 10/25).
#Health maintenance: Colonoscopy - review records, but reportedly had benign colonoscopy in 2022. Mammogram - R sided mammogram benign this month, repeat 3/25. S/p hysterectomy. DEXA age 65. Imms: not addressed this appointment