dmaec
True Blue
Below is an E/M visit that I had to audit and score out. If anyone has the time to score this out and let me know what they come up with (and how) I'd sure appreciate it. It is the exact note I reviewed to determine my level. This documentation has become the hot topic around here as far as what level it is, and why. I'll be bringing this note and my scoring E/M sheet to an E/M training class on August 28th. It will be interesting to see what they think too! Thanks for any input you have! I realize you'll probably have a few questions right off the bat, but please (that's part of my point), just work with what is written below. THANKS TONS!
SUBJECTIVE: Patient comes today with complaints of stabbing right ear pain and some sinus pain and pressure. He feels that this ear pain is constant over the past few days. He complains that he has had an ear infection two times for the past few years. He has tried over the counter Excedrin for the pain and he does get some relief from this. In the past for his sinuses he has tried nasal saline spray, has not done this on any consistent basis. He has had no fever, rhinorrhea or cough. He has had these symptoms on and off for the past month but worse in the last few days. He reports that he is normally healthy. No chronic diseases such as diabetes, heart, lung or kidney problems. Diabetes does run in his family and 20 years ago he passed out from hypoglycemia so he does make it a point to eat small frequent meals so this does not happen again. He has not had a routine physical in 3-5 years.
Routine medications: Multivitamin.
Allergies: No known medication allergies.
Risk factors: Smokes two packs per day for 37 years. Is contemplating quitting. Has quit in the past for as long as six months. This was a couple years ago. His wife is a smoker, she refused to smoke outside of the house. This made it difficult for him while he was attempting to quit and he subsequently resumed smoking again.
OBJECTIVE: Vital signs: Weight 218.6#, Height 58", Blood pressure 124/78, Temp 97.6, Pulse 76, Respirations 20.
Constitutional: Pleasant, alert and oriented X3, forty-two year old white male in no acute distress.
HEENT:
Head: Atraumatic, normocephalic.
Eyes: Sclerae clear, conjunctivae non injected. No drainage, no eyelid inflammation or swelling. Pupils equal, round and reactive to light and accommodation. Funduscopic exam essentially within normal limits.
Ears: External auditory canals patent. Tympanic membranes pearly gray, bony landmarks visualized. Light reflex intact and clear fluid noted behind the tympanic membranes.
Nose: Nasal mucosa erythematous with brown discoloration from nicotine. Swollen pharynx posterior mildly injected worse on the right. Tonsils non swollen no exudates. Uvula rises midline. Swallowing intact.
Neck: Supple, full range of motion, no lymphadenopathy.
Sinuses: Non tender to palpation, frontal and maxillary. No periorbital swelling. No facial swelling or erythema.
ASSESSMENT: 1) Eustachian tube dysfunction.
2) Pharyngitis.
3) Nasal congestion.
4) Tobacco addiction.
PLAN: Discussion with patient that the best way to improve his symptoms overall is for him to quit smoking. This was discussed with patient, he has been contemplating trying to quit and was pleased with his prior success. Has considered using Chantix. Risks and benefits of this was discussed today, a prescription was written for a starter pack with two refills. Would have him do symptomatic measures for the sore throat, including warm salt water gargles, ibuprofen or Tylenol as needed. For his nasal congestion would have him use Afrin nasal spray for no more than three days. Was cautioned regarding rebound congestion if he used this for longer than three days. Was also given a nasal steroid. Have him use the Afrin first, then wait an hour and use the nasal steroid. If the nasal steroid spray is helping him following a week and a half use he can continue using this two puffs each nostril everyday. If it is not helping, he should stop it. He verbalizes understanding and agreement with plan. Would also recommend that he follow up for routine preventative health maintenance.
SUBJECTIVE: Patient comes today with complaints of stabbing right ear pain and some sinus pain and pressure. He feels that this ear pain is constant over the past few days. He complains that he has had an ear infection two times for the past few years. He has tried over the counter Excedrin for the pain and he does get some relief from this. In the past for his sinuses he has tried nasal saline spray, has not done this on any consistent basis. He has had no fever, rhinorrhea or cough. He has had these symptoms on and off for the past month but worse in the last few days. He reports that he is normally healthy. No chronic diseases such as diabetes, heart, lung or kidney problems. Diabetes does run in his family and 20 years ago he passed out from hypoglycemia so he does make it a point to eat small frequent meals so this does not happen again. He has not had a routine physical in 3-5 years.
Routine medications: Multivitamin.
Allergies: No known medication allergies.
Risk factors: Smokes two packs per day for 37 years. Is contemplating quitting. Has quit in the past for as long as six months. This was a couple years ago. His wife is a smoker, she refused to smoke outside of the house. This made it difficult for him while he was attempting to quit and he subsequently resumed smoking again.
OBJECTIVE: Vital signs: Weight 218.6#, Height 58", Blood pressure 124/78, Temp 97.6, Pulse 76, Respirations 20.
Constitutional: Pleasant, alert and oriented X3, forty-two year old white male in no acute distress.
HEENT:
Head: Atraumatic, normocephalic.
Eyes: Sclerae clear, conjunctivae non injected. No drainage, no eyelid inflammation or swelling. Pupils equal, round and reactive to light and accommodation. Funduscopic exam essentially within normal limits.
Ears: External auditory canals patent. Tympanic membranes pearly gray, bony landmarks visualized. Light reflex intact and clear fluid noted behind the tympanic membranes.
Nose: Nasal mucosa erythematous with brown discoloration from nicotine. Swollen pharynx posterior mildly injected worse on the right. Tonsils non swollen no exudates. Uvula rises midline. Swallowing intact.
Neck: Supple, full range of motion, no lymphadenopathy.
Sinuses: Non tender to palpation, frontal and maxillary. No periorbital swelling. No facial swelling or erythema.
ASSESSMENT: 1) Eustachian tube dysfunction.
2) Pharyngitis.
3) Nasal congestion.
4) Tobacco addiction.
PLAN: Discussion with patient that the best way to improve his symptoms overall is for him to quit smoking. This was discussed with patient, he has been contemplating trying to quit and was pleased with his prior success. Has considered using Chantix. Risks and benefits of this was discussed today, a prescription was written for a starter pack with two refills. Would have him do symptomatic measures for the sore throat, including warm salt water gargles, ibuprofen or Tylenol as needed. For his nasal congestion would have him use Afrin nasal spray for no more than three days. Was cautioned regarding rebound congestion if he used this for longer than three days. Was also given a nasal steroid. Have him use the Afrin first, then wait an hour and use the nasal steroid. If the nasal steroid spray is helping him following a week and a half use he can continue using this two puffs each nostril everyday. If it is not helping, he should stop it. He verbalizes understanding and agreement with plan. Would also recommend that he follow up for routine preventative health maintenance.