atwill121
Guest
I am leaving something off and can not figure it out. Please help. I already have 99214, 338.4, 272.4, 796.2 719.41 786.50.
I have tried 334.0 (Friedreih's ataxia) and V58.61 for the Tylenol. that's not it
any help appreciated.
CHIEF COMPLAINT: Pain in right shoulder and right upper chest.
HISTORY OF PRESENT ILLNESS: Established 62 year old female patient with Friedreich's ataxia. She is in a wheelchair. She is complaining of some right shoulder and right upper chest pain. This has been an intermittent problem for a year or two. She does have chronic pain syndrome. She has hyperlipidemia and high blood pressure. She is on Zetia 10 mg per day. She takes Norvasc for high blood pressure. She has been on hydrocodone/APAP at the 7.5/500 dose, and she is taking 6 or 7 of these per day. I am concerned about the amount of Tylenol and am going to make some adjustments in her medications. She is a nonsmoker and a nondrinker.
PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure is 148/90. She is having pain today. Pulse is 70. Respirations 18. Temperature 97.9.
GENERAL: She is a well-developed, well-nourished female in no acute distress.
HEENT: Mucous membranes are pink and moist. TM's normal. Oropharynx normal.
LUNGS: Clear.
HEART: Regular rate and rhythm.
ABDOMEN: Soft. Bowel sounds are positive. There are no masses or tenderness. No organomegaly.
EXTREMITIES: No edema. No clubbing or cyanosis.
PSYCH: Mood and affect normal. Alert and oriented x3.
ASSESSMENT/PLAN: 1. She is to take hydrocodone/APAP 10/325 mg every 4 hours as needed. This should give her more pain control but significantly less acetaminophen. 2. Return to see me in 4 months with a chem-12, CBC, and a lipid. If she has new problems, she is to let me know.
I have tried 334.0 (Friedreih's ataxia) and V58.61 for the Tylenol. that's not it
any help appreciated.
CHIEF COMPLAINT: Pain in right shoulder and right upper chest.
HISTORY OF PRESENT ILLNESS: Established 62 year old female patient with Friedreich's ataxia. She is in a wheelchair. She is complaining of some right shoulder and right upper chest pain. This has been an intermittent problem for a year or two. She does have chronic pain syndrome. She has hyperlipidemia and high blood pressure. She is on Zetia 10 mg per day. She takes Norvasc for high blood pressure. She has been on hydrocodone/APAP at the 7.5/500 dose, and she is taking 6 or 7 of these per day. I am concerned about the amount of Tylenol and am going to make some adjustments in her medications. She is a nonsmoker and a nondrinker.
PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure is 148/90. She is having pain today. Pulse is 70. Respirations 18. Temperature 97.9.
GENERAL: She is a well-developed, well-nourished female in no acute distress.
HEENT: Mucous membranes are pink and moist. TM's normal. Oropharynx normal.
LUNGS: Clear.
HEART: Regular rate and rhythm.
ABDOMEN: Soft. Bowel sounds are positive. There are no masses or tenderness. No organomegaly.
EXTREMITIES: No edema. No clubbing or cyanosis.
PSYCH: Mood and affect normal. Alert and oriented x3.
ASSESSMENT/PLAN: 1. She is to take hydrocodone/APAP 10/325 mg every 4 hours as needed. This should give her more pain control but significantly less acetaminophen. 2. Return to see me in 4 months with a chem-12, CBC, and a lipid. If she has new problems, she is to let me know.