mrolf
Guest
Patient here for pre-op H&P for clearance of her HTN before she has excision of a ft foot Haglund deformity secondary to pain. She is also here for her annual exam and pap smear. Patient seen by PA.
Was here on 9/24 w/compliant of severe fatigue & crying all the time. She had been on prozac for a few yrs for depression but stopped it thinking that maybe that was causing her fatigue. When she came in she was very tearful. I checked her thyroid and her TSH was a little elevated but her free T4 was normal. Due to her symptoms I started on L-Thyroxine 25mg & Sertraline 25 mg daily. She said she is feeling much better and not tearful all the time but still some fatigue.
A complete PFSH was dictated and a complete ROS was dictated.Also a comprehensive exam was done. EKG was obtained and over-read by a physician. Shows sinus rhythm with no acute changes.
Impression:
Pre-op H&P for excision of rt foot Haglunds deformity
HTN controlled
Morbid obesity
Hypothyroidism, started on supplement
PLAN: Will schedule now for a CBC,BMP and fasting lipid. UA was done and negative. She is schedule for her mammogram. I refilled her ALdomet for 1 yr and increased her Sertraline up to 50mg w/refills for 1 yr. She is to call me in couple of months and let me know how she is doing on that dose of Sertaline. Will check thyroids again in November.
breast & pelvic exam
Depression, stable.
THe PA was wanting to bill a 99215. I just don't think this is correct. Please advise. Thanks.
Was here on 9/24 w/compliant of severe fatigue & crying all the time. She had been on prozac for a few yrs for depression but stopped it thinking that maybe that was causing her fatigue. When she came in she was very tearful. I checked her thyroid and her TSH was a little elevated but her free T4 was normal. Due to her symptoms I started on L-Thyroxine 25mg & Sertraline 25 mg daily. She said she is feeling much better and not tearful all the time but still some fatigue.
A complete PFSH was dictated and a complete ROS was dictated.Also a comprehensive exam was done. EKG was obtained and over-read by a physician. Shows sinus rhythm with no acute changes.
Impression:
Pre-op H&P for excision of rt foot Haglunds deformity
HTN controlled
Morbid obesity
Hypothyroidism, started on supplement
PLAN: Will schedule now for a CBC,BMP and fasting lipid. UA was done and negative. She is schedule for her mammogram. I refilled her ALdomet for 1 yr and increased her Sertraline up to 50mg w/refills for 1 yr. She is to call me in couple of months and let me know how she is doing on that dose of Sertaline. Will check thyroids again in November.
breast & pelvic exam
Depression, stable.
THe PA was wanting to bill a 99215. I just don't think this is correct. Please advise. Thanks.
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