99396 and 99214,25 ,
Here is the visit note. Complete;
Patient’s Care Team
BP: 140/78 sitting R arm 02/18/2019 10:30 am
138/78 sitting L arm 02/18/2019 10:31 am Pulse: 88 bpm regular02/18/2019 10:28 am Wt: 150 lbs With clothes 02/18/2019 10:28 am
Ht: 5 ft 6 in 02/18/2019 10:28 am BMI: 24.2 02/18/2019 10:28 am O2Sat: 98% Room Air at Rest02/18/2019 10:28 am
Allergies not reviewed (last reviewed 04/03/2017)
ALPRAZolam 0.25 mg tablet
Take 1 tablet(s) every day by oral route as needed. 02/07/17 filled PRIME
atorvastatin 10 mg tablet
TAKE 1 TABLET BY MOUTH DAILY 01/11/19 renewed
cinnamon bark-chromium picolinate-ALA 500 mg-100 mcg-150 mg capsule
Take by oral route. 02/07/17 entered
Co Q-10 100 mg capsule
Take 1 mg every day by oral route. 04/03/17 entered
diazePAM 5 mg tablet
Take 1 tablet(s) every day by oral route as needed for 5 days. 08/03/18 prescribed
Enteric Coated Aspirin 81 mg tablet,delayed release
Take 1 tablet(s) every day by oral route for 90 days. 02/18/19 prescribed
meclizine 25 mg tablet
Take 1 tablet(s) 3 times a day by oral route as needed for 10 days. 08/03/18 filled
Ocean Blue Omega-3 09/21/16 entered –
progesterone micronized (bulk) 100 % powder
Take 50mg progesterone, 0.5 mg of biest 80:20, DHEA 10mg in vaginal cream to be used nightly. 12/14/18 prescribed , DO
Restasis 0.05 % eye drops in a dropperette
INSTILL 1 DROP INTO AFFECTED EYE(S) BY OPHTHALMIC ROUTE EVERY 12 HOURS 10/12/15 entered –
Vitamin D3 2,000 unit capsule
Take 1 capsule(s) every day by oral route. 09/21/16 entered
Vaccine Type Date Amt. Route Site NDC Lot # Mfr. Exp.
on VIS VIS
Diphtheria, Tetanus, Pertussis
09/24/18 0.5 mL Intramuscular Arm, Left Upper u5872aa Sanofi Pasteur 02/06/20 02/24/15 09/24/18 TANYA SOLOMON-GIBBS
influenza, recombinant, quadrIvalent,injectable, preservative free
09/24/18 0.5 mL Intramuscular Arm, Right Upper qfaa1805 Protein Sciences 06/02/19 08/07/15 09/24/18 TANYA SOLOMON-GIBBS
influenza, injectable, quadrivalent, preservative free
11/20/17 0.5 mL Intramuscular Deltoid, Left ui892ab Sanofi Pasteur 06/06/18 08/07/15 11/20/17 TANYA SOLOMON-GIBBS
Some vaccines listed in Documents: #10643964, #10907796, #11877840, #11978595, #12114677, #12618937, #13156615, #13765252, #13829610, #14669904, #14733420 could not be added to this patient’s chart. Please review these documents and add these vaccines to the patient’s chart manually as needed.
Vitamin D deficiency – Onset: 11/12/2012 – LAST ASSESSED: 18 NOV 2013 10:33AM; TYPE: CHRONIC; LAST EDITED: 18 NOV 2013 10:46AM; STATUS: ACTIVE; LAST REVIEWED DATE: 20131118; PROBLEM CATEGORY: ACTIVE
Mixed hyperlipidemia – Onset: 02/18/2019
Anxiety state – Onset: 01/10/2014 – LAST ASSESSED: 10 JAN 2014 1:28PM; TYPE: CHRONIC; IDENTIFIED BY: GUNTHER, ELIZABETH; LAST EDITED: 10 JAN 2014 1:29PM; STATUS: ACTIVE; LAST REVIEWED DATE: 20140110; PROBLEM CATEGORY: ACTIVE
Anxiety – Onset: 02/18/2019
Benzodiazepine dependence – Onset: 02/18/2019
Tear film insufficiency – Onset: 04/23/2012 – LAST ASSESSED: 23 APR 2012 1:57PM; TYPE: CHRONIC; IDENTIFIED BY: BERKMAN, ANDREW; LAST EDITED: 23 OCT 2013 12:20AM; STATUS: ACTIVE; LAST REVIEWED DATE: 20131023; PROBLEM CATEGORY: ACTIVE
Chronic kidney disease stage 3 – Onset: 02/18/2019
Menopausal symptom – Onset: 11/12/2012 – LAST ASSESSED: 09 JUN 2015 10:04AM; TYPE: CHRONIC; IDENTIFIED BY: GUNTHER, ELIZABETH; LAST EDITED: 09 JUN 2015 10:05AM; STATUS: ACTIVE; LAST REVIEWED DATE: 20150609; PROBLEM CATEGORY: ACTIVE
Osteoporosis – Onset: 02/18/2019
Prediabetes – Onset: 02/18/2019
Extremely dense breast composition
Elevated blood-pressure reading without diagnosis of hypertension – Onset: 02/18/2019
Adult health examination – Onset: 02/18/2019
Screening for malignant neoplasm of colon – Onset: 02/18/2019
Screening for disorder – Onset: 02/18/2019
Body mass index 20-24 – normal – Onset: 02/18/2019
Discussed Family History
Mother – Primary malignant neoplasm of lung (onset age: 86) (died age: 86)
Father – Myocardial infarction (onset age: 40) (died age: 80)
– Dialysis for 2 years
Discussed Social History
Internal Medicine and Routine Gyn
Are you currently employed?: Y
Live alone or with others?: with others
Able to Care for Self: Y
Hard of hearing or deaf in one or both ears?: N
Legally blind in one or both eyes?: N
Alcohol intake: Occasional
Smoking Status: Never smoker
Tobacco-years of use: 0
Seat belts used routinely: Y
Performs monthly self-breast exam: Y
Reviewed Surgical History
Breast Biopsy – 07/23/2012 – MRI guided – negative
Appendectomy – 05/12/2002 – Severe rupture with peritonitis/post-operative abscess – Dr. Kearney
Breast Biopsy – 07/23/2000 – INCISIONAL BREAST BIOPSY – negative
Reviewed GYN History
Reviewed Obstetric History
Past Medical History
Discussed Past Medical History
High Cholesterol: Y
62F with PMH HL, CKD3 baseline Cr 1.1, prediabetes, anxiety/bzd dependence.
HL. tolerating meds. no myalgias, chest pain, dyspnea, orthopnea, palps, edema.
CKD3. avoid NSAIDs. urinating normally.
anxiety. bzd dependence. no si/sa/hi/ha, pt understands to call 911 immediately if any of these occur.
Patient reports no fever, no night sweats, no significant weight gain, no significant weight loss, and no change in appetite. She reports no change in vision, no eye discharge, and no eye discomfort. She reports no difficulty hearing and no ear pain. She reports no frequent nosebleeds, no sinus congestion, and no nasal discharge. She reports no sore throat, no bleeding gums, no dry mouth, no mouth ulcers, no change in sense of smell, and no change in sense of taste. She reports no chest pain, no exertional dyspnea, no orthopnea, no palpitations, and no syncope. She reports no cough, no sputum, no wheezing, no shortness of breath, no hemoptysis, and no pleuritic pain. She reports no dysphagia, no abdominal pain, no nausea, no vomiting, and no change in bowel habits. She reports no incontinence, no dysuria, no hematuria, no frequency, no vaginal bleeding, and no vaginal discharge. She reports no muscle aches, no muscle weakness, no joint pain, no back pain, and no joint swelling. She reports no abnormal mole, no rashes, and no wounds. She reports no weakness, no numbness, no seizures, no tremor, no dizziness, no headaches, no change in vision, no change in consciousness, and no confusion. She reports no depression, no sleep disturbances, no alcohol abuse, no anxiety, no hallucinations, no suicidal thoughts, and no drug abuse. She reports no fatigue, no temperature intolerance, no unusual weight change, no change in hair distribution, and no tremulousness. She reports no swollen glands, no unusual bruising, and no night sweats. She reports no itching, no hives, and no facial swelling.
Constitutional: General Appearance: well-nourished, well-developed, and well groomed. Level of Distress: NAD.
Head: Head: normocephalic and atraumatic.
Eyes: Lids and Conjunctivae: no discharge or pallor and non-injected. Pupils: PERRL. Corneas: clear. EOM: EOMI. Lens: clear. Sclerae: non-icteric and no injection.
ENMT: Ears: no lesions on external ear, EACs clear, and TMs clear. Nose: no lesions on external nose or nasal discharge and nares patent and nasal passages clear. Lips, Teeth, and Gums: no mouth or lip ulcers. Oropharynx: no erythema or exudates and moist mucous membranes.
Neck: Neck: supple, FROM, trachea midline, and no masses. Thyroid: no enlargement or nodules and non-tender.
Lymphatic System: Lymph Nodes: no cervical LAD or supraclavicular LAD.
Lungs: Respiratory effort: non labored breathing, normal expansion. Auscultation: no wheezing or rales; no rhonchi.
Cardiovascular: Heart Auscultation: no murmurs, rubs, or gallops and RRR; S1S2. Neck vessels: no carotid bruits. Pulses including femoral / pedal: normal throughout. Peripheral Edema absent.
Abdomen: Bowel Sounds: normal. Inspection and Palpation: no tenderness, guarding, masses, rebound tenderness, or CVA tenderness and soft, non-distended, and normal inspection. Liver: non-tender and no hepatomegaly. Spleen: non-tender and no splenomegaly. Hernia: none palpable.
Musculoskeletal:: Inspection and Palpation no tenderness or swelling. Range Of Motion Evaluation normal movement of all extremities.
Skin: Inspection and palpation: no rash or jaundice and good turgor.
Neurologic: Power/Tone: normal strength and tone. Gait and Station: normal gait and station. Sensation: grossly intact.
Psychiatric: Insight: good judgement and insight. Mental Status: normal mood and affect and active and alert. Orientation: to time, place, and person. Memory: recent memory normal and remote memory normal.
Assessment / Plan
1. Adult health examination – Preventative care: discussed/addressed advance directives (health care proxy), vaccinations, dieting, exercise, vision/hearing evaluations, dental examinations, wearing sun screen, seat belts, no texting while driving, medication adherence, appropriate laboratory testing
depression screening: neg
alcohol dependence: neg
smoking cessation: N/A never smoker
lung ca screening: N/A never smoker
crc screening: never had colonoscopy–counselled on importance of test and referred to GI for screening colonoscopy
breast/cervical ca screening: cbe/mammogram, routine gyn care/pap smear with gynecologist, Dr. Cavalleras
HCV screening: declined–discussed with pt rba and pt verbalized understanding and acceptance of risks
HIV screening:declined–discussed with pt rba and pt verbalized understanding and acceptance of risks
Z00.01: Encounter for general adult medical examination with abnormal findings
2. Screening for disorder –
Z13.89: Encounter for screening for other disorder
3. Screening for malignant neoplasm of breast
Z12.31: Encounter for screening mammogram for malignant neoplasm of breast
MAMMO, SCREENING, DIGITAL, BILATERAL
4. Screening for malignant neoplasm of colon
Z12.11: Encounter for screening for malignant neoplasm of colon
GASTROENTEROLOGY REFERRAL –
Schedule Within: provider’s discretion
5. Elevated blood-pressure reading without diagnosis of hypertension – -goal <130/80
-elevated today, previously controlled, monitor
R03.0: Elevated blood-pressure reading, without diagnosis of hypertension
6. Mixed hyperlipidemia – -LDL 114
-ASA 81mg, atorvastatin 10mg
E78.2: Mixed hyperlipidemia
Enteric Coated Aspirin 81 mg tablet,delayed release –
Take 1 tablet(s) every day by oral route for 90 days. Qty: 90 tablet(s) Refills: 1 Pharmacy: DRUG STORE 04594
7. Chronic kidney disease stage 3 – -CKD3 baseline Cr 1.1
-not on ACE/ARB, check AC ratio
N18.3: Chronic kidney disease, stage 3 (moderate)
CHRONIC KIDNEY DISEASE: CARE INSTRUCTIONS
MICROALBUMIN, RANDOM URINE (W/CREATININE)
MEDICINES TO AVOID WITH KIDNEY DISEASE: CARE INSTRUCTIONS
8. Body mass index 20-24 – normal –
diet/exercise/weight loss counselling
Z68.24: Body mass index (BMI) 24.0-24.9, adult
9. Prediabetes – -A1C 5.7
-diet/exercise/weight loss counselling
M81.0: Age-related osteoporosis without current pathological fracture
PHOSPHATE (AS PHOSPHORUS)
PTH, INTACT WITHOUT CALCIUM
11. Anxiety –
no si/sa/hi/ha, pt understands to call 911 immediately if any of these occur
F41.9: Anxiety disorder, unspecified
12. Benzodiazepine dependence – -dependent on diazepam 5mg to help control anxiety symptoms
-can discuss more in detail at future visit other options ie SSRI
F13.20: Sedative, hypnotic or anxiolytic dependence, uncomplicated