This 68-year-old established female presents to the office today for follow up of her hypertension. She has been doing
Posted: Fri Jul 01, 2022 9:05 am
This 68-year-old established female presents to the office todayfor follow up of her hypertension. She has been doingwell.
PAST MEDICAL HISTORY: She has a history of coronary arterydisease, status post coronary artery bypass x 3 in 1978. Gravida 3, para 3, postmenopausal about 20 years.
ALLERGIES: None.
MEDICATIONS: Digoxin 0.25 mg, Lasix 40 mg p.o. q.d.,estrogen.
SOCIAL HISTORY: Homemaker, mother of three. Does notsmoke. Occasional alcohol.
FAMILY HISTORY: Mother deceased from heart disease. Father has had multiple strokes.
REVIEW OF SYSTEMS: General: Well-developed,well-nourished female in no acute distress. GI: Deniesnausea, vomiting and diarrhea. GU: No dysuria,incontinence. Cardiovascular: Occasional bouts ofatrial fibrillation but always converts spontaneously.
PHYSICAL EXAM:General: Blood pressure 140/84, pulse 90 and regular, weight115 lb.HEENT: Wears glasses, otherwise negative.Respiratory: Negative.Endocrine: No diabetes or thyroid problems.Musculoskeletal: Some arthritis, both hands.Cardiovascular: Reveals a regular rhythm. I did nothear any murmurs or gallops.Skin: No skin lesions present.
ASSESSMENT AND PLAN:
Select one:
a.99213
b.99203
c.99202
d.99212
PAST MEDICAL HISTORY: She has a history of coronary arterydisease, status post coronary artery bypass x 3 in 1978. Gravida 3, para 3, postmenopausal about 20 years.
ALLERGIES: None.
MEDICATIONS: Digoxin 0.25 mg, Lasix 40 mg p.o. q.d.,estrogen.
SOCIAL HISTORY: Homemaker, mother of three. Does notsmoke. Occasional alcohol.
FAMILY HISTORY: Mother deceased from heart disease. Father has had multiple strokes.
REVIEW OF SYSTEMS: General: Well-developed,well-nourished female in no acute distress. GI: Deniesnausea, vomiting and diarrhea. GU: No dysuria,incontinence. Cardiovascular: Occasional bouts ofatrial fibrillation but always converts spontaneously.
PHYSICAL EXAM:General: Blood pressure 140/84, pulse 90 and regular, weight115 lb.HEENT: Wears glasses, otherwise negative.Respiratory: Negative.Endocrine: No diabetes or thyroid problems.Musculoskeletal: Some arthritis, both hands.Cardiovascular: Reveals a regular rhythm. I did nothear any murmurs or gallops.Skin: No skin lesions present.
ASSESSMENT AND PLAN:
Select one:
a.99213
b.99203
c.99202
d.99212