Is this something that we can even bill for? The patient doesn't have a chief complaint?
Time: 04:26 PM
Weight: 212 lbs
Temperature: 98.0 F (Oral)
Waist Circumference: 46 inches
BP: 118/60(Left Arm)(Sitting)
Pt here to have a letter stating that she has Asthma and Thyroid problems.
1 Albuterol Sulf Hfa 90 Mcg Inh Mcg/actuation (Other MD) SIG: Inhale 2 puff every 4-6 hours as needed
No Known Allergies
Social history was reviewed & updated on May 14, 2012 by MA.
currently smokes one pack per day . started smoking at the age of 12.
She denies alcohol use.
She denies recreational drug use.
Patient is married.
The patient does not do any form of exercise.
Caffeine intake consists of soda. She drinks 2 cans of soda per day.
Patient has no recent travel.
Family history reviewed and unchanged on Dec 22, 2011 by , LPN. Patient's father is deceased. He died at the age of 54 due to complications of diabetes. He suffered from congestive heart failure and diabetes type 1. Patient's mother is living. She is 45 years old., She has hyperthyroidism and lung cancer.
Patient has 5 brothers. All are in good health.
Patient has 1 sisters. Her first sister is older than her. She is 27 years old, has hypothyroidism and heart disease.
Patient has 1 sons.
Patient has 1 daughters. Patient's maternal grandmother has hyperthyroidism.
Reviewed & updated on May 14, 2012: allergies, current medication list, medical history, by MA.
Past medical history is unremarkable.
She has not been hospitalized or visited the ER in the last 12 months. Specialist(s) seen: Opthamology-Optometry: Dr. xxxx.
Surgical History: Surgical History:
Caesarean section Sept. 2009,.
Gallbladder surgery 1/2011.
OBGYN history was reviewed & updated on Dec 22, 2011 by, LPN. Menarche at age 12. Menstrual cycle is irregular, lasting 4 days, with flow light. Date of LMP:Feb 14, 2012 Gravida 3 para 2 . Connie is pregnant. Estimated due date is on Dec 2, 2012. She is not breastfeeding.
Hx of Gyn DX: No history of significant gynecologic illnesses.
No history of STD exposure or disease.
Patient has had no previous mammogram exam. Does not perform self breast exam. Patient is sexually active. Per pt hisotry, last PAP done 8/2010 which resulted negative.
20 year 11 month age old patient is here for request of a form
Per patient -she is dealing with immigration court for her spouse
She was told by their lawyer that she needs a "letter" stating she has medical conditions of thyroid problems and asthma
Patient has not followed up on any issues with the thyroid
PHQ reviewed.No follow-up or treatment needed at this time.
Current medications reviewed and updated. Past medical history, family history, and social history reviewed and updated. She has not follow up on any thyroid issues.
General: The patient is alert and active. She appears well groomed and in no acute distress. Vital signs noted.
Skin: Gross inspection of skin reveals no rash or lesions. Skin is warm and dry.
Respiratory: No respiratory distress.
GAIT: Normal gait.
Psychiatric: Appropriately dressed. Does not appear anxious or withdrawn. Speech and affect are appropriate.
PHQ: PHQ2: Over the last 2 weeks, how often have you been bothered by any of the following problems? Feeling Down, Depressed, or Hopeless? No Little Interest or Pleasure in Doing Things? No.
v68.9 Administrtve encount nos V22.2 Pregnant State, Incidental
Discontinued By Other MD: CHANTIX STARTING MONTH PAK 0.5 (11)-1 (42) MG
Patient Education/Counseling: Medications reviewed with patient including possible side effects, potential benefits and associated risks. Proper method of taking medications discussed. Status:stable.
MEDICATIONS: Current medications reviewed with patient including side effects, benefits and risks. Proper method of taking discussed.
FOLLOW-UP: Return to clinic as needed. Return sooner if the condition changes, worsens, or does not resolve..
INSTRUCTIONS: Go to ER if worsening. Drink plenty of fluids. OTHER: *** Patient had extensive discussion with patient over what the "letter" she needed was in regards to - how to fill it out. and she did not have the "letter" when this was discussed more she notes that there is no letter and she might just need her medical records.
Due to not following up she did not have diagnosis.