MLoadman
New
I got the primary diagnosis code and procedural code correct. But the rationale stated that my secondary diagnosis code Z79.2 was incorrect.
MEDICAL RECORD
OFFICE - ESTABLISHED
SEX: Male AGE: 24
DOS: 1/1/20XX
CC: Acne
HPI:
Duration: 6 years
Modifying Factors: Using Minocycline that helps
Location: face, back
Previously seen by Dr. Jones last year in this group practice
ROS:
Systemic: Not feeling tired or poorly. No fever, no chills, no night sweats, no recent involuntary weight loss, and no involuntary recent weight gain.
Head: No headache.
Neck: No swollen glands in the neck
Eyes: No vision problems.
Otolaryngeal: No earache, no nasal discharge, no nasal passage blockage, no sneezing, no hoarseness, no sore throat, and no bleeding gums.
Cardiovascular: No chest pain or discomfort and no palpitations.
Pulmonary: Dyspnea. No cough, not coughing up sputum, and no wheezing.
Gastrointestinal: No dysphagia, no heartburn, no vomiting, and no abdominal pain.
Genitourinary: No increase in urinary frequency. No dysuria.
Endocrine: No feeling weak.
Hematologic: No hematologic symptoms.
Musculoskeletal: No localized joint pain and no localized joint swelling.
Neurological: No dizziness, no motor disturbances, and no sensory disturbances.
Psychological: No anxiety and no depression.
Skin: Skin lesion: No change in a mole
Allergic and Immunologic: No allergic/immunologic symptoms. No GI upset, No Gray spots on the skin, No dizziness, Not have problems with eyes or teeth.
CURRENT MEDS:
Minocycline HC1 CAPS;; RPT
Albuterol Sulfate NEBU;;RPT
Advair Diskus 250-50 MCG/DOSE Inhalation Aerosol Powder Breath Activated; INHALE 1 PUFFS Every twelve hours; Rx
Albuterol Sulfate HFA; Take 1-2 puffs QID prn cough or shortness of breath; Rx
Fluticasone Propionate 50 MCG/ACT Nasal Suspension; Use 2 sprays in each nostril once a day for allergies,; Rx.
ALLERGIES:
Erythromycin Base CPEP
Erythromycin Derivatives.
ACTIVE PROBLEMS:
Acne
History of Allergic Rhinitis
Allergic Rhinitis - unclear how much allergies are playing a part right now .
History of Asthma
Normal Routine History And Physical Adolescent
Acute Pharyngitis
Acute Upper Respiratory Infection
Allergic Rhinitis
Asthma
Otitis Media Resolved
PERSONAL SOCIAL HX: Denied Alcohol Use Never a Smoker
PHYSICAL EXAM:
CONSTITUTIONAL; Healthy appearing, no acute distress
NEUROLOGIC/PSYCHIATRIC: Alert and oriented. Appropriate mood and affect
SKIN: Examination included the following
Face: perioral inflammatory papules face
Back: few scattered papules back
Assessment: Acne
Discussed Plan:
Acne: Minocycline two daily WITH FOOD and a large glass of liquid; can take one pill with breakfast, one with dinner or can take both at once if not too irritating to stomach.
CAN CAUSE SUN SENSITIVITY (higher risk of sunburn)
DO NOT LIE DOWN for at least an hour after taking the medicine (painful heartburn sensation can result).
STOP MEDICATION IF you notice any brown or gray spots on your skin, teeth, eyes, gums. Stop medication if you experience hives or other unusual rashes.
Stop medication if you experience dizziness, headaches, joint pain, fevers, chills, night sweats, nausea, or vomiting.
This medication can rarely cause liver damage.
Try to wean to 1 per day once under really good control—if flare then go back to 2 pills a day
Esteban Kramer, MD
Electronically signed by ESTEBAN KRAMER, MD 1/1/20XX
MEDICAL RECORD
OFFICE - ESTABLISHED
SEX: Male AGE: 24
DOS: 1/1/20XX
CC: Acne
HPI:
Duration: 6 years
Modifying Factors: Using Minocycline that helps
Location: face, back
Previously seen by Dr. Jones last year in this group practice
ROS:
Systemic: Not feeling tired or poorly. No fever, no chills, no night sweats, no recent involuntary weight loss, and no involuntary recent weight gain.
Head: No headache.
Neck: No swollen glands in the neck
Eyes: No vision problems.
Otolaryngeal: No earache, no nasal discharge, no nasal passage blockage, no sneezing, no hoarseness, no sore throat, and no bleeding gums.
Cardiovascular: No chest pain or discomfort and no palpitations.
Pulmonary: Dyspnea. No cough, not coughing up sputum, and no wheezing.
Gastrointestinal: No dysphagia, no heartburn, no vomiting, and no abdominal pain.
Genitourinary: No increase in urinary frequency. No dysuria.
Endocrine: No feeling weak.
Hematologic: No hematologic symptoms.
Musculoskeletal: No localized joint pain and no localized joint swelling.
Neurological: No dizziness, no motor disturbances, and no sensory disturbances.
Psychological: No anxiety and no depression.
Skin: Skin lesion: No change in a mole
Allergic and Immunologic: No allergic/immunologic symptoms. No GI upset, No Gray spots on the skin, No dizziness, Not have problems with eyes or teeth.
CURRENT MEDS:
Minocycline HC1 CAPS;; RPT
Albuterol Sulfate NEBU;;RPT
Advair Diskus 250-50 MCG/DOSE Inhalation Aerosol Powder Breath Activated; INHALE 1 PUFFS Every twelve hours; Rx
Albuterol Sulfate HFA; Take 1-2 puffs QID prn cough or shortness of breath; Rx
Fluticasone Propionate 50 MCG/ACT Nasal Suspension; Use 2 sprays in each nostril once a day for allergies,; Rx.
ALLERGIES:
Erythromycin Base CPEP
Erythromycin Derivatives.
ACTIVE PROBLEMS:
Acne
History of Allergic Rhinitis
Allergic Rhinitis - unclear how much allergies are playing a part right now .
History of Asthma
Normal Routine History And Physical Adolescent
Acute Pharyngitis
Acute Upper Respiratory Infection
Allergic Rhinitis
Asthma
Otitis Media Resolved
PERSONAL SOCIAL HX: Denied Alcohol Use Never a Smoker
PHYSICAL EXAM:
CONSTITUTIONAL; Healthy appearing, no acute distress
NEUROLOGIC/PSYCHIATRIC: Alert and oriented. Appropriate mood and affect
SKIN: Examination included the following
Face: perioral inflammatory papules face
Back: few scattered papules back
Assessment: Acne
Discussed Plan:
Acne: Minocycline two daily WITH FOOD and a large glass of liquid; can take one pill with breakfast, one with dinner or can take both at once if not too irritating to stomach.
CAN CAUSE SUN SENSITIVITY (higher risk of sunburn)
DO NOT LIE DOWN for at least an hour after taking the medicine (painful heartburn sensation can result).
STOP MEDICATION IF you notice any brown or gray spots on your skin, teeth, eyes, gums. Stop medication if you experience hives or other unusual rashes.
Stop medication if you experience dizziness, headaches, joint pain, fevers, chills, night sweats, nausea, or vomiting.
This medication can rarely cause liver damage.
Try to wean to 1 per day once under really good control—if flare then go back to 2 pills a day
Esteban Kramer, MD
Electronically signed by ESTEBAN KRAMER, MD 1/1/20XX