Complaint
f/u skin issues spot on back uses
would like referral to derm
also still has lump R lower chest. - needs to rt spirito for ? of surgical removal.
tore acl- never had it repaired. never f/u with ortho.
Vital Signs
AGE 21y11.6m
TEMPERATURE 97.3 F
BLOOD PRESSURE 114/72
WEIGHT 136 lb
BMI 21.7
Interval History
Illness/Injury since last visit? N
Specialty appointment since last visit? N
Hospitalization, Surgery, ER, Urgent visit since last visit? N
Social History
Pets in environment? N
Firearms in environment? N
TB Risk Status? Low
Education Attends school
Financial instability? N
Comments
pt immigrated to uS at age 8 in 1997 , needs ppd for college
Physical Exam
General Appearance
WDWN, NAD
Skin
tinea versoicolor over entire torso, back, hypopigmented dry and scaly. 4 cm soft mass R lower chest.
Assessment and Plan
Assesment
R acl needs f/u
tinea versicolor
mass R lower chest
Plan:
ortho f/u
derm consult
surgical f/u
Call/Return if worse or not better in:
RTO if worse sxs, new sxs or not improving.
Patient came in for his skin issues but then dr referred him to f/u on 2 other issues that were previously addressed that patient never saw specialist for. I believe this is a 99212. Dr wants to charge a 99214. any thoughts?? thanks
f/u skin issues spot on back uses
would like referral to derm
also still has lump R lower chest. - needs to rt spirito for ? of surgical removal.
tore acl- never had it repaired. never f/u with ortho.
Vital Signs
AGE 21y11.6m
TEMPERATURE 97.3 F
BLOOD PRESSURE 114/72
WEIGHT 136 lb
BMI 21.7
Interval History
Illness/Injury since last visit? N
Specialty appointment since last visit? N
Hospitalization, Surgery, ER, Urgent visit since last visit? N
Social History
Pets in environment? N
Firearms in environment? N
TB Risk Status? Low
Education Attends school
Financial instability? N
Comments
pt immigrated to uS at age 8 in 1997 , needs ppd for college
Physical Exam
General Appearance
WDWN, NAD
Skin
tinea versoicolor over entire torso, back, hypopigmented dry and scaly. 4 cm soft mass R lower chest.
Assessment and Plan
Assesment
R acl needs f/u
tinea versicolor
mass R lower chest
Plan:
ortho f/u
derm consult
surgical f/u
Call/Return if worse or not better in:
RTO if worse sxs, new sxs or not improving.
Patient came in for his skin issues but then dr referred him to f/u on 2 other issues that were previously addressed that patient never saw specialist for. I believe this is a 99212. Dr wants to charge a 99214. any thoughts?? thanks