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Est Patient here for Preop appt
Subjective
CC: Patient presents for preoperative visit. Laser surgery scheduled for 11/06/xx and treatment of perineal warts.
HPI:
ROS:
Const: Denies weight gain and unexplained weight loss. General health stated as good.
Resp: Denies chronic cough, coughing up blood, SOB and wheezing.
Gl: Denies constipation and diarrhea.
GU: Genital: denies dysmenorrhea and menorrhagia. Urinary: denies frequency and urgency.
Breast: Denies discharge, masses and pain.
Endocrine: Denies hot flashes.
Allergy/Immuno: Denies allergic/immunologic symptoms.
Current Meds: Invega 9 mg, Lexapro 20 mg, Advair Diskus 250/50, Nasonex 50 mcg/act, Albuterol 90 mcg/act, Aerochamber Plus, Xanax XR 1 mg, Topamax 100 mg, Glucophage 1000 mg, Abilify 10mg
Allergies: Prozac, Bee Stings, Tape, Ativan, Aleve, Ibuprofen - Rash, Toradol - Itching, DarvocetN-100 - N-V, Seroquel
PMH:
Medical Problems: IDDM, Genital Herpes, Multiple Personality Disorder, Severe Depression
Surgeries: Dilation & Curettage, Tonsillectomy, Laser To Cervix, Herpes- Genital
OB/Gyn Hx: Gravidity: (2) Parity: Living (2)
Reviewed, no changes.
FH:
Father: Deceased due to Schitzophrenia.
Mother: BI-POLAR
Reviewed, no changes.
SH:
Marital: divorced. Lives With: Mother. Smoke Free: Home is not smoke-free. Work Status: Not
Currently Working. Advance Directive: Negative For Living Will
Personal Habits: Cigarette Use: current cigarette smoker. Current Cigarette Smoker 1 Pack
Daily. Alcohol: Denies alcohol use. Drug Use: Denies Drug Use.
Reviewed, no changes.
Objective
Wt: 183 Wt Prior: 183 as of 10/23/xx Wt Dif: 0 BP: 115/72 Ht 66" 5'6" LMP: 10/23/xx
Exam:
Const: Appears the stated age, healthy and well groomed. Appears moderately overweight. Alert and oriented.
Resp: Auscultate good airflow.
CV: Rate is within normal range. No heart murmur appreciated.
Abdomen: Abdomen is soft, nontender, and nondstended without guarding, rigidity or rebound tenderness.
GU: Exam deferred until procedure .
Lymph: No palpable lymphadenopathy in the subclavicular or suprclavicular region(s).
Musculo: Normal muscle tone.
Skin: Skin is warm and dry.
Assessment & Plan #1: Viral Warts Unspec:
Comments : Discussed laser procedure including risks. Discussed sitz baths, vicodin for pain and silvedene cream for after procedure. Patients questions answered. Instructed to stop glucophage 48 hours before procedure.
I have the cpt and icd 9 codes I thought were correct but it keeps saying I need more.
Please help
Subjective
CC: Patient presents for preoperative visit. Laser surgery scheduled for 11/06/xx and treatment of perineal warts.
HPI:
ROS:
Const: Denies weight gain and unexplained weight loss. General health stated as good.
Resp: Denies chronic cough, coughing up blood, SOB and wheezing.
Gl: Denies constipation and diarrhea.
GU: Genital: denies dysmenorrhea and menorrhagia. Urinary: denies frequency and urgency.
Breast: Denies discharge, masses and pain.
Endocrine: Denies hot flashes.
Allergy/Immuno: Denies allergic/immunologic symptoms.
Current Meds: Invega 9 mg, Lexapro 20 mg, Advair Diskus 250/50, Nasonex 50 mcg/act, Albuterol 90 mcg/act, Aerochamber Plus, Xanax XR 1 mg, Topamax 100 mg, Glucophage 1000 mg, Abilify 10mg
Allergies: Prozac, Bee Stings, Tape, Ativan, Aleve, Ibuprofen - Rash, Toradol - Itching, DarvocetN-100 - N-V, Seroquel
PMH:
Medical Problems: IDDM, Genital Herpes, Multiple Personality Disorder, Severe Depression
Surgeries: Dilation & Curettage, Tonsillectomy, Laser To Cervix, Herpes- Genital
OB/Gyn Hx: Gravidity: (2) Parity: Living (2)
Reviewed, no changes.
FH:
Father: Deceased due to Schitzophrenia.
Mother: BI-POLAR
Reviewed, no changes.
SH:
Marital: divorced. Lives With: Mother. Smoke Free: Home is not smoke-free. Work Status: Not
Currently Working. Advance Directive: Negative For Living Will
Personal Habits: Cigarette Use: current cigarette smoker. Current Cigarette Smoker 1 Pack
Daily. Alcohol: Denies alcohol use. Drug Use: Denies Drug Use.
Reviewed, no changes.
Objective
Wt: 183 Wt Prior: 183 as of 10/23/xx Wt Dif: 0 BP: 115/72 Ht 66" 5'6" LMP: 10/23/xx
Exam:
Const: Appears the stated age, healthy and well groomed. Appears moderately overweight. Alert and oriented.
Resp: Auscultate good airflow.
CV: Rate is within normal range. No heart murmur appreciated.
Abdomen: Abdomen is soft, nontender, and nondstended without guarding, rigidity or rebound tenderness.
GU: Exam deferred until procedure .
Lymph: No palpable lymphadenopathy in the subclavicular or suprclavicular region(s).
Musculo: Normal muscle tone.
Skin: Skin is warm and dry.
Assessment & Plan #1: Viral Warts Unspec:
Comments : Discussed laser procedure including risks. Discussed sitz baths, vicodin for pain and silvedene cream for after procedure. Patients questions answered. Instructed to stop glucophage 48 hours before procedure.
I have the cpt and icd 9 codes I thought were correct but it keeps saying I need more.
Please help