STAT E&M: ID 21876
LABEL 1: ID 21876
LABEL 2: Dr Smith
SERVICE: Tue 8/12/03
AUDITED: Wed 10/15/03 9:32 pm
USERNAME: fjmjonesmd
TYPE: Office/Outpt. Visit, New
======== HISTORY ========
History Level: Detailed
- HPI: Extended (5 elements)
•Location
•Severity
•Duration
•Context
•Modifying factors
- ROS: Extended (8)
•Constitutional symptoms
•Eyes
•Ears, Nose, Mouth, Throat
•Respiratory
•Gastrointestinal
•Neurological
•Endocrine
•Psychiatric
- PFSH: Complete (3)
•Past history
•Family history
•Social history | ====== EXAMINATION ======
Exam Level: Comprehensive
(31 elements; 14 categories)
Exam Type: General Multi-System
- Constitutional
•3 vital signs
•general appearance
- Eyes
•conjunctivae & lids
•pupils & irises
- Ears, nose, mouth & throat
•otoscopic exam
•oropharynx
- Neck
•examination of neck
•thyroid
- Respiratory
•auscultation of lungs
•respiratory effort
- Cardiovascular
•auscultation of heart
•palpation of heart
•extremity edema & varicosities
•femoral arteries
•pedal pulses
- Chest (Breasts)
•inspection of breasts
•palpation of breasts & axillae
- Gastrointestinal (Abdomen)
•exam. masses/tenderness
•liver & spleen
- Male Genitourinary
•scrotal contents
•penis
- Female Genitourinary
•external genitalia
•bladder
- Lymphatic
•neck
•axillae
- Skin
•inspection
•palpation
- Neurologic
•cranial nerves
•deep tendon reflexes
- Psychiatric
•mood & affect
•orientation | == MEDICAL DECISIONMAKING ==
MDM Level: Low Complexity
- # of Dx: Limited*
•Problem 1: Established - Stable
•Problem 2: Established - Stable
- Data: Limited*
•Lab tests:
•Obtain records:
- Risk: Moderate*
•Problem Risk:
Acute illness w/systemic Sx (mod)
•Management Risk:
Rx drug; IV med; closed fx (mod)
*Counts towards MDM level
==== OVERALL CODE: 99203 ====
COMMENT: Dx CHF
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