Case Studies

A new patient with stable hypertension and diabetes 

CC: “I need a primary physician.”

HPI: The patient is a pleasant 82 years old gentleman who presents to establish care with a local physician after relocating to that area.  He has a history of hypertension and diabetes, both of which have been fairly control with routine medications.  He also reports a history of coronary artery disease.He has no current complaints.

Medications
Amlodipine 10 mg PO QD
Metformin 500 mg PO BID
Atenolol  50 mg PO BID
Atorvastatin 20 mg PO QD

Past Medical History : per HPI and dyslipidemia.

Family History: Father at age 72 of pneumonia.  The patient has two grown children in good health.

Social History: The patient has been married for 36 years.  He denies tobacco or alcohol abuse and continues to drive himself around.

ROS:

CONSTITUTIONAL:  No weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes:  No visual loss, blurred vision, doubles vision or yellow sclera. Ears, Nose, Throat:  No hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  No rash or itching.

CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  No shortness of breath, cough or sputum.

GASTROINTESTINAL:  No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  Burning on urination. .

NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  No muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  No anemia, bleeding or bruising.

LYMPHATICS:  No enlarged nodes.

PSYCHIATRIC:  No history of depression or anxiety.

ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  No history of asthma, hives, eczema or rhinitis

Physical Exam

Vitals: 130/80, 88, 98.6

General appearance: NAD, conversant

Eyes: anicteric sclera, moist conjunctiva; no lid-lag; PERRLA

HEENT: AT/NC; oropharynx clear with MMM and no mucosal  ulcerations; auditory canals patent with pearly TMs
normal hard and soft palate

Neck: Trachea midline; FROM, supple, no lymphadenopathy

Lungs: CTA, with normal respiratory effort and no intercostal retractions

CV: RRR, no MRGs

Abdomen: Soft, non-tender; no masses or HSM

Extremities: No peripheral edema or extremity lymphadenopathy

Skin: Normal temperature, turgor and texture; no rash, ulcers or nodules

Psych: Appropriate affect, alert and oriented to person, place and time

Labs: HGBA1c 6.8; BUN 25, creatinine 0.8; LDL 88, HGB 12

Assessment

  1. Well controlled essential hypertension
  2. Controlled DM
  3. Stable dyslipidemia
  4. Stable CAD

Plan

  1. Continue current medications unchanged
  2. Return visit in two months
  3. Will check LFTs since patient is on statin medication
  4. Will also repeat HGBA1c, CBC, and renal profile

What is the correct E/M code?

  1. a) 99201
  2. b) 99202
  3. c) 99204
  4. d) 99214

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