twalls
Networker
Pt comes back in for results of the colonoscopy, they have already come in for a pre-appt that wasn't billable because they were healthy, now they are coming for their results...unnecessary? Thanks for your thoughts..my thought is send him a letter and see pts that need to be seen. ![Confused :confused: :confused:](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)
HISTORY OF PRESENT ILLNESS: ..... is a 55-year-old male who
comes to the office on 01/31/2019 for a followup for a
colonoscopy. The colonoscopy, the patient states that he had a
good prep. It did not make him sick. He does not remember the
procedure, and he had no ill effects from the procedure. He is
in zero type pain at the present time.
PHYSICAL EXAMINATION: General: Demonstrates a 55-year-old
white male, oriented x3, pleasant and cooperative.
Vital Signs: Temperature 97.6, pulse 57, respirations 20, BP of
132/78, 6 feet tall, 248 pounds, 97% on room air. 0 pain at the
present time.
Lungs: Clear to auscultation bilaterally. No rales, rhonchi or
friction rubs. No wheezing. Normal respiratory effort. No
shortness of breath.
Heart: Regular rate and rhythm. No S3 or S4 sounds are heard.
No chest pain during the examination. No bruits heard over the
carotids or aorta. No swelling to the lower extremities.
Abdomen: No masses in the abdomen. No tenderness. No
organomegaly. No evidence of hernia.
We reviewed the following material for this visit.
CURRENT MEDICATIONS: We reviewed his medication list.
IMAGING: We reviewed the chest x-ray from 01/04/2019.
LABORATORY: We reviewed his blood work from January 4, 2019.
We reviewed his colonoscopy from 01/25/2019, which demonstrated
2 polyps. We reviewed the pathology report from 01/25/2019,
which demonstrated the 2 polyps to be adenomatous polyps. One
is a pure adenoma, the other one was a tubular adenoma. No
evidence of dysplasia, metaplasia or cancer.
We reviewed the consultation from 01/02/2019.
IMPRESSION: We have a healthy 55-year-old white male who grows
adenomatous polyps.
RECOMMENDATIONS: A repeat colonoscopy in 2 years.
HISTORY OF PRESENT ILLNESS: ..... is a 55-year-old male who
comes to the office on 01/31/2019 for a followup for a
colonoscopy. The colonoscopy, the patient states that he had a
good prep. It did not make him sick. He does not remember the
procedure, and he had no ill effects from the procedure. He is
in zero type pain at the present time.
PHYSICAL EXAMINATION: General: Demonstrates a 55-year-old
white male, oriented x3, pleasant and cooperative.
Vital Signs: Temperature 97.6, pulse 57, respirations 20, BP of
132/78, 6 feet tall, 248 pounds, 97% on room air. 0 pain at the
present time.
Lungs: Clear to auscultation bilaterally. No rales, rhonchi or
friction rubs. No wheezing. Normal respiratory effort. No
shortness of breath.
Heart: Regular rate and rhythm. No S3 or S4 sounds are heard.
No chest pain during the examination. No bruits heard over the
carotids or aorta. No swelling to the lower extremities.
Abdomen: No masses in the abdomen. No tenderness. No
organomegaly. No evidence of hernia.
We reviewed the following material for this visit.
CURRENT MEDICATIONS: We reviewed his medication list.
IMAGING: We reviewed the chest x-ray from 01/04/2019.
LABORATORY: We reviewed his blood work from January 4, 2019.
We reviewed his colonoscopy from 01/25/2019, which demonstrated
2 polyps. We reviewed the pathology report from 01/25/2019,
which demonstrated the 2 polyps to be adenomatous polyps. One
is a pure adenoma, the other one was a tubular adenoma. No
evidence of dysplasia, metaplasia or cancer.
We reviewed the consultation from 01/02/2019.
IMPRESSION: We have a healthy 55-year-old white male who grows
adenomatous polyps.
RECOMMENDATIONS: A repeat colonoscopy in 2 years.