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.
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.
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
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
What is the correct E/M code?