mlsstnt@aol.com
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I bill Indiana Workers Comp and I cant fiqure out a dx code for this patient please see attached dictation I will add a E code but Im still looking for a primary dx please help
CHIEF COMPLAINT: Over all check up- rolled Bobcat
HISTORY OF PRESENT ILLNESS: This is the initial visit for Kenneth Roberts, a 50 year-old male, His pain level is 0/10. Patient states he has been with the company for 3 years. Patient states he was in a bobcat going up a hill, lifting up a log, when the bobcat started to jump around and flipped slowly back. Nothing was hurt and he has no pain. Patient states supervisor wanted him checked out. Gwen Davis, CMA
REVIEW OF SYSTEMS: Musculoskeletal: Negative for pain, weakness, joint stiffness. Neurological: Negative for headache, numbness, tingling. Endocrine: Negative for diabetes, thyroid disease.
PAST, FAMILY AND SOCIAL HISTORY: Current Work Status: Working full time. Marital Status: Yes Prior Surgery: Yes - left eye Smoking: No
CURRENT MEDICATONS: None
ALLERGIES: NKDA
VITAL SIGNS: Height: 70 inches. Weight: 185 pounds. BMI: 26.6 [Overweight]. Blood Pressure: 122/84. Pulse: 64/min. Respirations: 12/min.
PHYSICAL EXAMINATION: Inversion of bobcat, patient inside, but restrained. Patient is A&A, Ox4. He recalls incident. He denies any HA, dizziness, pain or discomfort. He has good ROM of his neck and back and no discomfort with palpation. He has no discomfort with palpation over entire spine. He has good pulses, sensation, grip, capillary refill, ROM and resisted ROM of upper extremities. He has normal gait, his CN II-XII are intact. PEARRLA. No c/o dizziness immediately after incident. Patient denies any nausea either at time of exam or immediately following accident. No discomfort with palpation and pressure laterally over his rib cage or over T-spine and sternum. Abdomen is soft/non-rigid. Judith L Smith, PA-C
DIAGNOSIS: No pain or discomfort with ROM (after inversion of bobcat). No LOC.
MEDICAL DECISION MAKING: Exam. Provided patient with Biofreeze, in case he begins to stiffen up this evening or in the morning. Shown some stretches for neck, to do as needed.
TREATMENT PLAN: Patient understands he may return for any problems or concerns.
MEDICAL CAUSATION: This problem is related to work activities.
WORK CAPACITY: Patient can return to regular duty. Released.
Thank you Melissa
CHIEF COMPLAINT: Over all check up- rolled Bobcat
HISTORY OF PRESENT ILLNESS: This is the initial visit for Kenneth Roberts, a 50 year-old male, His pain level is 0/10. Patient states he has been with the company for 3 years. Patient states he was in a bobcat going up a hill, lifting up a log, when the bobcat started to jump around and flipped slowly back. Nothing was hurt and he has no pain. Patient states supervisor wanted him checked out. Gwen Davis, CMA
REVIEW OF SYSTEMS: Musculoskeletal: Negative for pain, weakness, joint stiffness. Neurological: Negative for headache, numbness, tingling. Endocrine: Negative for diabetes, thyroid disease.
PAST, FAMILY AND SOCIAL HISTORY: Current Work Status: Working full time. Marital Status: Yes Prior Surgery: Yes - left eye Smoking: No
CURRENT MEDICATONS: None
ALLERGIES: NKDA
VITAL SIGNS: Height: 70 inches. Weight: 185 pounds. BMI: 26.6 [Overweight]. Blood Pressure: 122/84. Pulse: 64/min. Respirations: 12/min.
PHYSICAL EXAMINATION: Inversion of bobcat, patient inside, but restrained. Patient is A&A, Ox4. He recalls incident. He denies any HA, dizziness, pain or discomfort. He has good ROM of his neck and back and no discomfort with palpation. He has no discomfort with palpation over entire spine. He has good pulses, sensation, grip, capillary refill, ROM and resisted ROM of upper extremities. He has normal gait, his CN II-XII are intact. PEARRLA. No c/o dizziness immediately after incident. Patient denies any nausea either at time of exam or immediately following accident. No discomfort with palpation and pressure laterally over his rib cage or over T-spine and sternum. Abdomen is soft/non-rigid. Judith L Smith, PA-C
DIAGNOSIS: No pain or discomfort with ROM (after inversion of bobcat). No LOC.
MEDICAL DECISION MAKING: Exam. Provided patient with Biofreeze, in case he begins to stiffen up this evening or in the morning. Shown some stretches for neck, to do as needed.
TREATMENT PLAN: Patient understands he may return for any problems or concerns.
MEDICAL CAUSATION: This problem is related to work activities.
WORK CAPACITY: Patient can return to regular duty. Released.
Thank you Melissa
