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Case Of The Week: 6/18/08
 

 

E/M Coding Rounds Case of the Week: 6/18/08

Is this really a level-four office visit (99214)?

CC:  HTN and dyslipidemia.

INTERVAL HISTORY:  The patient feels fine. He has no somatic complaints.


Medications: amlodipine 10 mg PO QD, simvastatin 10 mg PO QD


PHYSICAL EXAMINATION:  GENERAL: NAD; looks stated age. BP 164/82, HR 84, RR 18. Eyes: Anicteric sclerae. Neck: No JVD or carotid bruits. Lungs: CTA with normal respiratory effort. CV: RRR with no MRGs; normal PMI in the MCL. ABD: Soft, non-tender; normal aortic pulsations. EXT: No peripheral edema; brisk, symmetric pedal pulses.


LABORATORY INFORMATION:  LDL 77, HDL 54 


IMPRESSION:

  1. Poorly controlled HTN.
  2. Stable dyslipidemia.

PLAN:

  1. Continue simvastatin
  2. Continue amlodipine
  3. Add lisinopril 20 mg PO QD
  4. RTC in six weeks with renal profile and LFTs.

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