CC: DM, HTN, and Hypothyroidism.
HPI: He complains of left hip pain-LOCATION
with activity such as walking or shoveling-CONTEXT
He thinks ED started at the same time of his hip surgery-TIMING
He has a normal libido. He is interested in meds for ED. He thinks that fasting blood glucoses are ranging about 170 to 150.-SEVERITY
Denies polyuria or polydipsia.-ROS-GU
I got an extensive level for HPI. I did it 2 ways. First: The note discussing the status of 3 chronic illnesses-this would give you the extensive under 1997. Second: I used the elements from 1995 to see what I could come up with. I capitalize above. The elements can be pulled from several different issues, not just one.
And, the MDM: 1) DM. Suspect control will be poor. ESTABLISHED PROBLEM, NOT RESOLVING-2 POINTS
Need f/u glycohemoglobin and urine micro alubumin-LAB-ADDITIONAL WORK UP-1 POINT. He may need to add sulfourea to regimen to achieve glycemic control. 2) HTN. Control is good.-ESTABLISHED PROBLEM-CONTROLLED-1 POINT Will continue same antihypertensive regimen-RX DRUG MANAGEMENT. Need clarification on atenolol usage.
3) Actinic Keratosis. With pts consent, 6 keratoses were destroyed using liquid nitrogen dual freeze technique.-COULD BE A NEW PROBLEM OR AN EST, NOT HEALING AS EXPECTED-EITHER 3 OR 2 POINTS
4) Dyslipidemia. Needs F/u lipid panel to monitor gemfibrozil use.-ESTABLISHED PROBLEM 1 POINT
DX OPTIONS: 5-6 POINTS
DATA: 1 POINT
COULD BE A MODERATE RISK MDM.
I hope all of this helps.
I alread know the CPT code for the Karatosis. I am just looking for the MDM level. Thoughts? Feedback??
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