Coder evals

CC: 3-month follow-up, established patient.
HPI: 58 y/o with type 2 diabetes, hypertension and hyperlipidemia. Home glucose 120-150 fasting. No hypoglycemia. BP at home 130s/80s. Taking metformin, lisinopril, atorvastatin without side effects. Denies chest pain, polyuria, foot ulcers.
Exam: BP 134/82, BMI 31. Feet: monofilament intact bilaterally, no lesions.
A/P: 1. Type 2 diabetes without complications, at goal, continue metformin, A1c today. 2. Hypertension, controlled, continue lisinopril. 3. Hyperlipidemia, continue atorvastatin, lipid panel. Blood drawn in clinic by venipuncture. RTC 3 months.
MDM: moderate (three chronic illnesses, prescription drug management).

CC: Sore throat x2 days. New patient to the practice.
HPI: 24 y/o with sore throat, fever to 101.2 at home, odynophagia. No cough. Sick contact at work with strep.
Exam: T 100.8. Tonsillar exudate, tender anterior cervical nodes. Lungs clear.
Rapid strep antigen positive in clinic.
A/P: Streptococcal pharyngitis. Amoxicillin 500 mg BID x10 days. Return if worse.
MDM: low, new patient.

CC: Right knee pain, established patient.
HPI: 67 y/o with known osteoarthritis of the right knee, worse over 6 weeks, pain with stairs, no locking, no trauma. Tried acetaminophen with partial relief. Also here for hypertension follow-up, BP log at home 128-138 systolic, tolerating amlodipine.
Exam: Right knee mild effusion, crepitus, ROM 0-120, stable ligaments. BP 136/84.
Procedure: After verbal consent, sterile prep, 40 mg triamcinolone with 4 mL lidocaine injected into the right knee via anterolateral approach. Tolerated well.
A/P: 1. Osteoarthritis of the right knee, injected today, PT referral. 2. Hypertension, continue amlodipine, recheck 3 months.
MDM: low. Separately identifiable E/M for the hypertension management.

CC: Cut on right hand while washing a glass 2 hours ago.
HPI: 34 y/o, 2.0 cm laceration to the dorsum of the right hand, bleeding controlled with pressure. No numbness or weakness. Tetanus up to date (2023). No foreign body sensation.
Exam: 2.0 cm linear laceration, dorsum right hand, no tendon exposure, full finger ROM and sensation intact. Wound explored, no glass seen.
Procedure: Irrigated with 250 mL saline, anesthetized with 1% lidocaine, closed with 4 simple interrupted 4-0 nylon sutures. Dressing applied.
A/P: Laceration of the right hand, simple repair. Suture removal 10 days. Wound care reviewed.

CC: Decreased hearing both ears, established patient.
HPI: 72 y/o with gradually muffled hearing bilaterally over a month, no pain, no drainage, no tinnitus. Uses cotton swabs.
Exam: Bilateral impacted cerumen fully occluding both canals. TMs not visualized initially.
Procedure: Removed the impacted cerumen from both ears with a curette and warm water irrigation under otoscopic visualization. TMs intact and normal after removal.
A/P: Cerumen impaction bilaterally, removed. Hearing subjectively restored. Counseled to stop cotton swabs.

CC: Annual physical, established patient, age 52.
HPI: No complaints. Exercises 3x/week, nonsmoker, no alcohol concerns. Reviewed immunization history, colon cancer screening up to date.
Exam: Comprehensive exam normal. BP 118/76, BMI 24.
Preventive: Age-appropriate counseling on diet, exercise and screening. Quadrivalent influenza vaccine, preservative free, 0.5 mL administered intramuscularly in the left deltoid, no reaction.
A/P: Preventive visit, no abnormal findings. Immunization for influenza given today. RTC 1 year.

CC: Shortness of breath x3 days, established patient.
HPI: 66 y/o with COPD on tiotropium, worsening dyspnea, increased sputum volume and purulence, using rescue albuterol 6x/day. No fever, no chest pain. 40 pack-year former smoker.
Exam: SpO2 91% RA, RR 22, diffuse expiratory wheeze, prolonged expiration. No accessory muscle use.
Treatment: Albuterol nebulizer treatment 2.5 mg given in clinic, post-treatment SpO2 94%, wheeze improved.
A/P: Acute exacerbation of her COPD. Prednisone 40 mg x5 days, doxycycline x5 days, continue tiotropium. Return precautions given, ER if worse.
MDM: moderate. E/M separately identifiable from the nebulizer treatment.

CC: Mood follow-up, established patient.
HPI: 41 y/o with major depressive disorder, recurrent, moderate, on sertraline 100 mg for 8 weeks. PHQ-9 today 12, down from 19. Reports insomnia with sleep onset delay 60+ minutes most nights, no early waking. Denies SI/HI.
Exam: Alert, cooperative, affect brighter than last visit.
A/P: 1. Major depressive disorder, recurrent, moderate, improving, increase sertraline to 150 mg. 2. Insomnia, sleep hygiene reviewed, CBT-I referral, no hypnotic for now.
MDM: moderate (chronic illness with progression, prescription drug management).

CC: Diabetes follow-up, established patient.
HPI: 61 y/o with type 2 diabetes, uncontrolled, A1c 9.4 last month, on insulin glargine 30 units nightly plus metformin. Fasting glucose 190-240. No hypoglycemia. Denies neuropathic symptoms.
Exam: BMI 33, feet without lesions, sensation intact.
A/P: Diabetes with hyperglycemia. Increase insulin glargine to 36 units, titration instructions given, RTC 4 weeks, CDE referral. Long-term insulin use documented.
MDM: moderate.

CC: Dysuria x2 days, established patient. HPI: 29 y/o with dysuria, frequency, no fever, no flank pain. Exam: Suprapubic tenderness, no CVA tenderness. Urine dipstick in clinic positive for leukocyte esterase and nitrite. A/P: Urinary tract infection, nitrofurantoin x5 days. MDM: low.

CC: Congestion and cough x4 days, established patient. HPI: 38 y/o with nasal congestion, cough, low-grade temp, no dyspnea. Exam: T 99.4, TMs normal, pharynx mildly erythematous without exudate, lungs clear. A/P: Viral URI, supportive care, return if worse. MDM: straightforward.

CC: Palpitations, established patient. HPI: 70 y/o with intermittent palpitations x1 week, no syncope, no chest pain. Exam: Irregularly irregular rhythm, rate 96. 12-lead ECG in clinic interpreted by me: atrial fibrillation, rate 94, no acute ST changes. A/P: Atrial fibrillation, new. Start apixaban after CHA2DS2-VASc discussion, cardiology referral, echo ordered. MDM: high.

CC: Red painful right shin, established patient. HPI: 55 y/o with 3 days of spreading redness and warmth on the right lower leg after a scratch, no fever, no drainage. Exam: 8x6 cm erythema, warmth, tenderness, no fluctuance, no abscess. A/P: Cellulitis of the right lower leg, cephalexin x7 days, mark borders, return in 48 hours. MDM: moderate.

CC: Rough spots on forehead, established patient. HPI: 63 y/o with three scaly lesions on the forehead x months. Exam: Three 4-6 mm rough erythematous papules consistent with actinic keratoses. Procedure: Cryotherapy with liquid nitrogen to all three lesions, 2 freeze-thaw cycles each, tolerated well. A/P: Actinic keratosis x3, treated. Sun protection counseled. Recheck 8 weeks.

CC: Anxiety follow-up, established patient. HPI: 33 y/o with generalized anxiety disorder on escitalopram 10 mg, GAD-7 today 9 from 16. No side effects. Denies depression, denies SI. A/P: Generalized anxiety disorder, improving, continue escitalopram, RTC 3 months. MDM: low.

CC: Cough and fever, established patient. HPI: 45 y/o with productive cough and fever to 102 for 3 days, pleuritic right-sided pain, no dyspnea at rest. Exam: T 101.6, SpO2 95%, crackles right base. Chest x-ray from urgent care yesterday shows right lower lobe consolidation. A/P: Community-acquired pneumonia, right lower lobe, amoxicillin-clavulanate x7 days, return precautions. MDM: moderate.