Donna Lambert
Member
Hi Everyone,
I need your opionion. How would you code this scenerio?
Chief Complaint: Pain
HPI: Pt returns for reevaluation of lower back, rt knee & sexual dysfunction. Pt describes pain as sharp, stabbing, aching and aggravated by sitting, standing, walking & alleviated by meds.
Medical Prob: No data for serious illnesses/hospitalizations
Surgical History: No data for Operations
Bowel regimen: Over the counter
Review of Sys: dizziness
Physcial Exam: height, weight, bmi, pulse, b/p - all recorded
Normal lumbar lordosis. Increased pain with lumbar extention. Straight leg raising test is neg. Rt. knee shows no significant effusion. Tenderness over the medial joint line as well as at the pes anserine bursa.
Problem List: lower back pain rt knee osteoarthiritis, hypertension, hypercholesterolemia, sexual dysfunction
Plan of care: lower back - new prescription, rt knee gel, sexual dysfunction - new prescription
Any input would be greatly appreciated. Thanks
Donna
I need your opionion. How would you code this scenerio?
Chief Complaint: Pain
HPI: Pt returns for reevaluation of lower back, rt knee & sexual dysfunction. Pt describes pain as sharp, stabbing, aching and aggravated by sitting, standing, walking & alleviated by meds.
Medical Prob: No data for serious illnesses/hospitalizations
Surgical History: No data for Operations
Bowel regimen: Over the counter
Review of Sys: dizziness
Physcial Exam: height, weight, bmi, pulse, b/p - all recorded
Normal lumbar lordosis. Increased pain with lumbar extention. Straight leg raising test is neg. Rt. knee shows no significant effusion. Tenderness over the medial joint line as well as at the pes anserine bursa.
Problem List: lower back pain rt knee osteoarthiritis, hypertension, hypercholesterolemia, sexual dysfunction
Plan of care: lower back - new prescription, rt knee gel, sexual dysfunction - new prescription
Any input would be greatly appreciated. Thanks
Donna