sankoe@keystoneruralhealth.com
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I feel like its appropriate to add an additional E/M addressing patient complaint fatigue along with a preventative. Am I correct and after review I believe the E/M would be 99213 and also should the fatigue be updated to lymes disease since it came back positive since we have a definitive dx for the symptoms presented with.
Chief Complaint: Preventative visit
pt is concerned he might have a tick born illness due to having a fever last month for a few days, no energy and still has no energy
pt does not get flu shot
Ifit given with instructions to return upon completion
Today's PHQ-9 Score: 0
Last FIT:
NOT DETECTED (08/18/2017 9:43:58 PM)
Last PHQ-9:
May 21, 2018 (05/21/2018 9:13:06 AM)
HISTORY OF PRESENT ILLNESS
Patient age:
68 Years Old
Patient presents for yearly preventive physical.
Last month, he had a fever 101-102, and fatigue. Started first week of July. Went away for a week and came back. States he still does not have much energy since that time. Has not noted any tick bites. No joint pains. No rashes. No abdominal pain. No n/v/d. No mental status changes.
Cholesterol: 183 (05/22/2018 6:52:45 PM)
LDL: 120 (05/22/2018 6:52:45 PM)
HDL: 43 (05/22/2018 6:52:45 PM)
TRIG: 99 (05/22/2018 6:52:45 PM)
Impaired fasting glucose. Due for fasting labs.
Hyperlipidemia. Stable, due for fasting labs.
Lung nodules seen 8/2017 on low dose screening CT.
CT of Chest at PHE 8/16/18: Previously described small nodules in the left upper lobe and right middle lobe are unchanged and do not require additional follow up.
Past Medical History:
Reviewed history from 05/26/2016 and no changes required:
Glaucoma
Past Surgical History:
Reviewed history from 05/26/2016 and no changes required:
Appendectomy
Allergy Medication Problem Directive Form
Allergies Reviewed
No Known Allergies
Medications Reviewed
COMBIGAN 0.2-0.5 % OPHTHALMIC SOLUTION (BRIMONIDINE TARTRATE-TIMOLOL) uses as directed; Route: OPHTHALMIC
VIAGRA 100 MG ORAL TABLET (SILDENAFIL CITRATE) 1/2 to 1 tab PO 1 h prior to intercourse.; Route: ORAL
LUMIGAN 0.01 % OPHTHALMIC SOLUTION (BIMATOPROST) instill 1 drop into both eyes once daily at bedtime; Route: OPHTHALMIC
Problems
Problems Reviewed
Fever (ICD-780.60) (ICD10-R50.9)
Fatigue (ICD-780.79) (ICD10-R53.83)
Preventive health care (ICD-V70.0) (ICD10-Z00.00)
Hyperlipidemia (ICD-272.4) (ICD10-E78.5)
Impaired fasting glucose (ICD-790.21) (ICD10-R73.01)
Adult healthy physical (ICD-V70.0) (ICD10-Z00.00)
Family History Summary:
Family History of Other Cancer for Brother - Entered On: 8/12/2019
Removed Family History of No Known Family History - On: 8/12/2019
Family History Reviewed: 08/12/2019
Review of Systems
General
Complains of fever.
Denies weakness.
fever has resolved
Eyes
Denies double vision, blurring and eye pain.
ENT
Denies earache, difficulty swallowing, hoarseness and sore throat.
CV
Denies chest pain or discomfort, palpitations and swelling of hands or feet.
Resp
Denies cough, shortness of breath, coughing up blood and wheezing.
GI
Denies nausea, vomiting, diarrhea, dark tarry stools and bloody stools.
GU
Denies dysuria, urinary frequency and incontinence.
MS
Denies loss of strength and muscle aches.
Derm
Denies suspicious lesions and rash.
Neuro
Denies disturbances in coordination, seizures and tremors.
Psych
Denies thoughts of suicide, mental problems and depression.
Endo
Denies cold intolerance, heat intolerance and weight change.
Vital Signs
Entered weight: 192 lbs., 4 oz. Calculated Weight: 192.25 lbs., ( 87.20 kg)
Entered height: 71.00 in., Calculated Height: 71.00 in., ( 180.34 cm)Temperature: 98.0 deg F, ( 36.67 deg C) Temperature site: oral
Pulse rate: 72 Respirations: 18
Blood Pressure #1: 108 / 72 mm Hg
BMI: 26.81 BSA (m2): 2.07 Wt Chg: -5.75 lbs since 05/21/2018Wt Chg: -2.61 kg since 05/21/2018
Pain Assessment
The patient is not currently experiencing pain.
The patient does not experience chronic pain.
Vitals entered by: on August 12, 2019 9:02 AM
Vitals updated by: on August 12, 2019 9:02 AM
Pulse Oximetry
O2 Saturation: 98 %
Physical Exam
General:
well developed, well nourished, in no acute distress.
Head:
normocephalic and atraumatic.
Eyes:
PERRL/EOM intact, conjunctiva and sclera clear with out nystagmus.
Ears:
Cerumen obscures EAC bilaterally.
Mouth:
Normal pharynx.
Lungs:
Clear to auscultation bilaterally, no wheezes, rales, or rhonchi
Heart:
Regular rate and rhythm; no murmurs, rubs, or gallops; S1 and S2
Abdomen:
Soft, nondistended, bowel sounds normal in all four quadrants. Nontender. No guarding or rebound tenderness.
Pulses:
Right radial pulse 2+, regular
Extremities:
No edema of bilateral lower extremities
Cervical Nodes:
no significant adenopathy.
Blood Pressure:
Today's BP: 108/72 mm Hg
Labwork:
Most Recent Lab Results:
LDL: 120 mg/dL 05/22/2018
HbA1c: : 5.8 % 05/22/2018
DIABETIC FOOT EXAM
Assessment/Plan
# 1: Preventive health care (ICD-V70.0) (ICD10-Z00.00)
ASSESSMENT: Unchanged.
PLAN:
Test Orders
# 2: Impaired fasting glucose (ICD-790.21) (ICD10-R73.01)
ASSESSMENT: Unchanged.
PLAN:
Test Orders:
Hemoglobin A1C (CPT-83036). At: Laboratory.
# 3: Hyperlipidemia (ICD-272.4) (ICD10-E78.5)
ASSESSMENT: Unchanged.
PLAN:
Test Orders:
Complete Metabolic Panel (Q10231X;L322000). At: Laboratory.
Lipid Profile (Q968T;L303756). At: Laboratory.
# 4: Fatigue (ICD-780.79) (ICD10-R53.83)
ASSESSMENT: Unchanged.
PLAN:
Test Orders:
CBC with Differential (Q6399x;L005009). At: Laboratory.
TSH with Free T4 (reflex) (43562A). At: Laboratory.
Rapid Lyme Test (In House) (RapidLyme). At: Laboratory.
Anaplasmosis IGG; IGM / E.Chaffee AB (10611X). At: Laboratory.
Rapid lyme disease testing is positive. A lyme disease IgM/IgG with reflex to western blot is ordered.
Patient Instructions:
1) Follow up in 1 year.
Problems:
Added new problem of Fatigue (ICD-780.79) (ICD10-R53.83)
Added new problem of Fever (ICD-780.60) (ICD10-R50.9)
Assessed Impaired fasting glucose as unchanged
Assessed Preventive health care as unchanged
Assessed Hyperlipidemia as unchanged
Assessed Fatigue as unchanged
Process Orders
Check Orders Results:
Laboratory: Order checked:
496X -- Hemoglobin A1C -- ABN may be required due to frequency restrictions. (CPT: 83036)
43562A -- TSH with Free T4 (reflex) -- ABN may be required due to frequency restrictions. (CPT: 84443)
968T -- Lipid Profile -- ABN may be required due to frequency restrictions. (CPT: 80061)
-- InFit Stool Cards (mail) -- [NO CODE FOUND]
-- Rapid Lyme Test (In House) -- [NO CODE FOUND]
Tests Sent for requisitioning (August 12, 2019 9:51 AM):
08/12/2019: Laboratory -- InFit Stool Cards (mail) [NOCHARGE] (signed)
08/12/2019: Laboratory -- Anaplasmosis IGG, IGM / E.Chaffee AB [10611X] (signed)
08/12/2019: Laboratory -- Rapid Lyme Test (In House) [RapidLyme] (signed)
08/12/2019: Laboratory -- TSH with Free T4 (reflex) [43562A] (signed)
08/12/2019: Laboratory -- CBC with Differential [Q6399x,L005009] (signed)
08/12/2019: Laboratory -- Hemoglobin A1C [CPT-83036] (signed)
08/12/2019: Laboratory -- Lipid Profile [Q968T,L303756] (signed)
08/12/2019: Laboratory -- Complete Metabolic Panel [Q10231X,L322000] (signed)
08/12/2019: Laboratory -- Lyme Ab (IgM IgG) w/refl blot [6646] (signed)
Recommendations:
PNU vaccine (once after 65)
Influenza vaccination (annually)
Hepatitis B vaccination (if medium/high risk)
Mammogram (annually for women over 40)
Prostate Cancer Screening (annually for men age 50-75)
Colorectal Cancer Screening (50 to age 75)
Fecal occult blood test (annually)
Sigmoidoscopy (5y)
Screening colonscopy (10y)
Osteoporosis screening (women over 65)
Diabetes self management training (if diabetic)
Glaucoma Screening (yearly over age 65)
Cardiovascular screening blood tests (every 5 years)
Total cholesterol
HDL
Triglycerides
Diabetes screening tests (every 3 years)
AAA screening (once)
HIV/STD screening (if high risk yearly)
Smoking cessation counseling (every visit)
Laboratory Results
Other Tests:
Date/Time Received: August 12, 2019 9:35 AM
Rapid Lyme: positive
Chief Complaint: Preventative visit
pt is concerned he might have a tick born illness due to having a fever last month for a few days, no energy and still has no energy
pt does not get flu shot
Ifit given with instructions to return upon completion
Today's PHQ-9 Score: 0
Last FIT:
NOT DETECTED (08/18/2017 9:43:58 PM)
Last PHQ-9:
May 21, 2018 (05/21/2018 9:13:06 AM)
HISTORY OF PRESENT ILLNESS
Patient age:
68 Years Old
Patient presents for yearly preventive physical.
Last month, he had a fever 101-102, and fatigue. Started first week of July. Went away for a week and came back. States he still does not have much energy since that time. Has not noted any tick bites. No joint pains. No rashes. No abdominal pain. No n/v/d. No mental status changes.
Cholesterol: 183 (05/22/2018 6:52:45 PM)
LDL: 120 (05/22/2018 6:52:45 PM)
HDL: 43 (05/22/2018 6:52:45 PM)
TRIG: 99 (05/22/2018 6:52:45 PM)
Impaired fasting glucose. Due for fasting labs.
Hyperlipidemia. Stable, due for fasting labs.
Lung nodules seen 8/2017 on low dose screening CT.
CT of Chest at PHE 8/16/18: Previously described small nodules in the left upper lobe and right middle lobe are unchanged and do not require additional follow up.
Past Medical History:
Reviewed history from 05/26/2016 and no changes required:
Glaucoma
Past Surgical History:
Reviewed history from 05/26/2016 and no changes required:
Appendectomy
Allergy Medication Problem Directive Form
Allergies Reviewed
No Known Allergies
Medications Reviewed
COMBIGAN 0.2-0.5 % OPHTHALMIC SOLUTION (BRIMONIDINE TARTRATE-TIMOLOL) uses as directed; Route: OPHTHALMIC
VIAGRA 100 MG ORAL TABLET (SILDENAFIL CITRATE) 1/2 to 1 tab PO 1 h prior to intercourse.; Route: ORAL
LUMIGAN 0.01 % OPHTHALMIC SOLUTION (BIMATOPROST) instill 1 drop into both eyes once daily at bedtime; Route: OPHTHALMIC
Problems
Problems Reviewed
Fever (ICD-780.60) (ICD10-R50.9)
Fatigue (ICD-780.79) (ICD10-R53.83)
Preventive health care (ICD-V70.0) (ICD10-Z00.00)
Hyperlipidemia (ICD-272.4) (ICD10-E78.5)
Impaired fasting glucose (ICD-790.21) (ICD10-R73.01)
Adult healthy physical (ICD-V70.0) (ICD10-Z00.00)
Family History Summary:
Family History of Other Cancer for Brother - Entered On: 8/12/2019
Removed Family History of No Known Family History - On: 8/12/2019
Family History Reviewed: 08/12/2019
Review of Systems
General
Complains of fever.
Denies weakness.
fever has resolved
Eyes
Denies double vision, blurring and eye pain.
ENT
Denies earache, difficulty swallowing, hoarseness and sore throat.
CV
Denies chest pain or discomfort, palpitations and swelling of hands or feet.
Resp
Denies cough, shortness of breath, coughing up blood and wheezing.
GI
Denies nausea, vomiting, diarrhea, dark tarry stools and bloody stools.
GU
Denies dysuria, urinary frequency and incontinence.
MS
Denies loss of strength and muscle aches.
Derm
Denies suspicious lesions and rash.
Neuro
Denies disturbances in coordination, seizures and tremors.
Psych
Denies thoughts of suicide, mental problems and depression.
Endo
Denies cold intolerance, heat intolerance and weight change.
Vital Signs
Entered weight: 192 lbs., 4 oz. Calculated Weight: 192.25 lbs., ( 87.20 kg)
Entered height: 71.00 in., Calculated Height: 71.00 in., ( 180.34 cm)Temperature: 98.0 deg F, ( 36.67 deg C) Temperature site: oral
Pulse rate: 72 Respirations: 18
Blood Pressure #1: 108 / 72 mm Hg
BMI: 26.81 BSA (m2): 2.07 Wt Chg: -5.75 lbs since 05/21/2018Wt Chg: -2.61 kg since 05/21/2018
Pain Assessment
The patient is not currently experiencing pain.
The patient does not experience chronic pain.
Vitals entered by: on August 12, 2019 9:02 AM
Vitals updated by: on August 12, 2019 9:02 AM
Pulse Oximetry
O2 Saturation: 98 %
Physical Exam
General:
well developed, well nourished, in no acute distress.
Head:
normocephalic and atraumatic.
Eyes:
PERRL/EOM intact, conjunctiva and sclera clear with out nystagmus.
Ears:
Cerumen obscures EAC bilaterally.
Mouth:
Normal pharynx.
Lungs:
Clear to auscultation bilaterally, no wheezes, rales, or rhonchi
Heart:
Regular rate and rhythm; no murmurs, rubs, or gallops; S1 and S2
Abdomen:
Soft, nondistended, bowel sounds normal in all four quadrants. Nontender. No guarding or rebound tenderness.
Pulses:
Right radial pulse 2+, regular
Extremities:
No edema of bilateral lower extremities
Cervical Nodes:
no significant adenopathy.
Blood Pressure:
Today's BP: 108/72 mm Hg
Labwork:
Most Recent Lab Results:
LDL: 120 mg/dL 05/22/2018
HbA1c: : 5.8 % 05/22/2018
DIABETIC FOOT EXAM
Assessment/Plan
# 1: Preventive health care (ICD-V70.0) (ICD10-Z00.00)
ASSESSMENT: Unchanged.
PLAN:
Test Orders
# 2: Impaired fasting glucose (ICD-790.21) (ICD10-R73.01)
ASSESSMENT: Unchanged.
PLAN:
Test Orders:
Hemoglobin A1C (CPT-83036). At: Laboratory.
# 3: Hyperlipidemia (ICD-272.4) (ICD10-E78.5)
ASSESSMENT: Unchanged.
PLAN:
Test Orders:
Complete Metabolic Panel (Q10231X;L322000). At: Laboratory.
Lipid Profile (Q968T;L303756). At: Laboratory.
# 4: Fatigue (ICD-780.79) (ICD10-R53.83)
ASSESSMENT: Unchanged.
PLAN:
Test Orders:
CBC with Differential (Q6399x;L005009). At: Laboratory.
TSH with Free T4 (reflex) (43562A). At: Laboratory.
Rapid Lyme Test (In House) (RapidLyme). At: Laboratory.
Anaplasmosis IGG; IGM / E.Chaffee AB (10611X). At: Laboratory.
Rapid lyme disease testing is positive. A lyme disease IgM/IgG with reflex to western blot is ordered.
Patient Instructions:
1) Follow up in 1 year.
Problems:
Added new problem of Fatigue (ICD-780.79) (ICD10-R53.83)
Added new problem of Fever (ICD-780.60) (ICD10-R50.9)
Assessed Impaired fasting glucose as unchanged
Assessed Preventive health care as unchanged
Assessed Hyperlipidemia as unchanged
Assessed Fatigue as unchanged
Process Orders
Check Orders Results:
Laboratory: Order checked:
496X -- Hemoglobin A1C -- ABN may be required due to frequency restrictions. (CPT: 83036)
43562A -- TSH with Free T4 (reflex) -- ABN may be required due to frequency restrictions. (CPT: 84443)
968T -- Lipid Profile -- ABN may be required due to frequency restrictions. (CPT: 80061)
-- InFit Stool Cards (mail) -- [NO CODE FOUND]
-- Rapid Lyme Test (In House) -- [NO CODE FOUND]
Tests Sent for requisitioning (August 12, 2019 9:51 AM):
08/12/2019: Laboratory -- InFit Stool Cards (mail) [NOCHARGE] (signed)
08/12/2019: Laboratory -- Anaplasmosis IGG, IGM / E.Chaffee AB [10611X] (signed)
08/12/2019: Laboratory -- Rapid Lyme Test (In House) [RapidLyme] (signed)
08/12/2019: Laboratory -- TSH with Free T4 (reflex) [43562A] (signed)
08/12/2019: Laboratory -- CBC with Differential [Q6399x,L005009] (signed)
08/12/2019: Laboratory -- Hemoglobin A1C [CPT-83036] (signed)
08/12/2019: Laboratory -- Lipid Profile [Q968T,L303756] (signed)
08/12/2019: Laboratory -- Complete Metabolic Panel [Q10231X,L322000] (signed)
08/12/2019: Laboratory -- Lyme Ab (IgM IgG) w/refl blot [6646] (signed)
Recommendations:
PNU vaccine (once after 65)
Influenza vaccination (annually)
Hepatitis B vaccination (if medium/high risk)
Mammogram (annually for women over 40)
Prostate Cancer Screening (annually for men age 50-75)
Colorectal Cancer Screening (50 to age 75)
Fecal occult blood test (annually)
Sigmoidoscopy (5y)
Screening colonscopy (10y)
Osteoporosis screening (women over 65)
Diabetes self management training (if diabetic)
Glaucoma Screening (yearly over age 65)
Cardiovascular screening blood tests (every 5 years)
Total cholesterol
HDL
Triglycerides
Diabetes screening tests (every 3 years)
AAA screening (once)
HIV/STD screening (if high risk yearly)
Smoking cessation counseling (every visit)
Laboratory Results
Other Tests:
Date/Time Received: August 12, 2019 9:35 AM
Rapid Lyme: positive