1. what are the diagnoses codes for this case? 2. what is the correct code for a...
Question:
1. what are the diagnoses codes for this case?
2. what is the correct code for a type of obesity for this has patient?
3. what is the GRED code for this patient case?
OFFICE VIST
Patient: John Spettman
DOB: 5/1962
Date of Encounter 3/9 / 2013
Chief Complaint: Malaise, fatigue, insomnia for 3 weeks ,worse during day time. patient today claims he has no problem swallowing, no shortness of breath and no chest pains.
Past Medical History: Patient has hypertension and hyperlipidemia Patient is taking atenolol, lovastatin and cimetidine.
Social History: Patient is married and was in the military for 25 years until his health problems necessitated an honorable discharge.
The patient is a 51-year- old African- American male who has long- standing hyperlipidemia and hypertension . He has a history of esophageal dilatation for swallowing difficulties. Today he denies any SOB or chest pain. He mentions that is reflux is much improved on the cimetidine . I will schedule a followup EGD for three months. The patient is severely overweight , but he is not motivated to lose weight. He does not restrict his diet in any way and refuses to engage in any sort of physical activity. His morbid obesity is of no concern to the patient . Nor is the possibility of stroke or MI.
Vital signs today show a slightly elevated blood pressure of 145/89, heart rate of 100 beats per minute and a weight of 267. Patient has gained 3 pounds since his last appointment two months ago .
However, his physical examination today is relatively normal. His GERD much improved on the cimetidine so we will continue that and do repeat EDG in 3 months. Patient is moderately depressed although can't really find a cause. He did suffer a setback at work 6 months ago and this seems to be contributing to his depression. I will put him on a trial of Celexa until his next visit to see if this helps with the depression.
WHAT Evaluation and Management Code is the best code for this office encounter?
Expert Answer:
1The diagnosis codes for this case would depend on the specific conditions that the patient is being ... View the full answer
