Primary Care Established Office Visit # 4

Primary Care Established Office Visit # 4

CC: Recheck of the right ear. (Chief Complaint)

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HPI: The patient is a 64 yr. old male with a past medical history (PFSH = Past Medical History) of CABG, kidney transplant and IBD who is presenting for a recheck on the right ear(HPI = location) from the office visit from 07/13/06(HPI = Duration). During that office visit, it wasdetermined that the patient had plugged(HPI = quality) right ear. At that time, he did have some congestion(HPI = Assoc S&S) of his nose and two days of plugging in the right ear. He was given prescription for Claritin-D (HPI = Modifying Factor) during which time, the patient does notethat he still has complaints of fullness in the right ear. The patient denies any upper respiratory tract infection(ROS Resp), but however, he did have some nasal (ROS ENT) congestion along with associated ear fullness. The patient at this time denies any dizziness(ROS Neuro), otorrhea, or otalgia.

Past Medical History: includes kidney transplant and CABG.(PFSH = Past Medical HX)

Current medications includes Prograf 1 mg. p.o. once per day, CellCept 1,000 mg., metroprolol 50 mg. once per day, metformin 500 mg. magnesium oxide, Ecotrin, lisinopril, Lantus and NovoLog. (PFSH = Past Medical HX)

ALLERGIES: No known drug allergies. (PFSH = Past Medical HX)

HISTORY = Extended (4+) HPI + Extended ROS (3) + Pertinent HX (1 area) = Detailed History

PHYSICAL EXAMINATION: (CMS/WPS 95 DG Exam) (CMS 97 DG GMS Exam)

Constitutional Blood pressure is 118/76. Respirations are 16. Pulse is 72. The patient is a 64 yr. old male in no acute distress. (2 bullets for vitals and general appearance)

Eye HEENT: PERRLA. EOMI. (1 bullet for examination of pupils and irises)

ENT Moist mucous membranes. There is drainage of the right tympanic membrane with air-fluid level. Posterior tympanic membrane is intact bilaterally and there is some mild cerumen in bilateral ear canals. (2 bullets for exam TM, mucous membranes)

Respiratory Lungs: Clear to auscultation bilaterally. (1 bullet for ausc lungs)

Cardiovascular Cardiac: Regular rate and rhythm. Normal S1 and S2. No murmurs, gallops, or heaves. (1 bullet for ausc heart)

Gastrointestinal Abdomen: Soft, nontender and nondistended. Positive bowel sounds in all four quandrants. (1 bullet for exam of abd)

Also CV Extemities: No clubbing, cyanosis, or edema. He has 2+ pulses bilaterally.(2 bullets for edema, pulses)

CMS 95 DG = 6 systems (no system in detail) = Expanded Problem Focused Exam

WPS 95 DG = 6 systems = Detailed Exam

CMC 97 GMS Exam = 10 bullets = Expanded Problem Focused Exam

ASSESSMENT AND PLAN: 1. Otitis media. The patient will be given a prescription for Augmentin. He was asked to follow up in one week’s time. Considering the patient’s symptoms, the patient will be sent to Otolaryngology as well for further evaluation.

MDM # DX options = 2 pts, established problem, worsening

2. Diabetes. The patient’s last hemoglobin AIC was 7.9. The patient is currently on Lantus, NovoLog as well as metformin.

MDM # DX options = 1 pt, established problem

MDM Data Review = 1 pt, review/order lab

MDM Risk = Moderate, Prescription Drug Management

MDM = 3 pts Dx options + 1 pt Data Review + Moderate Risk = Moderate MDM

CMS 95 = Detailed History + Expanded Problem Focused Exam + Moderate MDM = 99214

WPS 95 = Detailed History + Detailed Exam + Moderate MDM = 99214

CMS 97 GMS = Detailed History + Expanded Problem Focused Exam + Moderate MDM = 99214

ICD 9 Coding

1. Otitis Media 382.9

2. Diabetes 250.00

Type not specified

3. Renal Transplant Status V42.0