01/01/XX SUBJECTIVE: CC: This 43 year-old Caucasian male is…
01/01/XX SUBJECTIVE: CC: This 43 year-old Caucasian male is here today for a follow-up visit. The patient’s past medical history is notable for diabetes, hypertension, and mixed hyperlipidemia. HPI: Patient presents with type 2 diabetes. Specifically, this is type 2, non-insulin requiring diabetes without complications. Compliance with treatment has been good. In regard to the essential hypertension, benign, this was first diagnosed several years ago. He is tolerating the medication well without side effects. Concerning mixed hyperlipidemia, compliance with treatment has been good; he takes his medication as directed, maintains his low cholesterol diet, follows up as directed, and maintains his exercise regimen. ROS: CONSTITUTIONAL: Negative for chills, fatigue, fever and night sweats. CARDIOVASCULAR: Negative for chest pain, claudication, dizziness, palpitations and pedal edema. RESPIRATORY: Negative for dyspnea, hemoptysis and pleuritic chest pain. GASTROINTESTINAL: Negative for abdominal pain, dysphagia, constipation, diarrhea, heartburn, nausea and vomiting. Past Medical, Family, Social History (PFSH): Past Medical History: Coronary Artery Disease Hyperlipidemia Hypertension Surgical History: Appendectomy: at age 27; Tobacco/Alcohol/Supplements: Tobacco: Currently smokes more than three packs per day. An extensive list of the risks of smoking (and reasons to quit) have been reviewed with the patient; these include increased risk of cancer and increased risk of heart attack. Is unwilling to consider quitting tobacco at this time. Alcohol: Patient has a past history of alcoholism. His last drink was over 10 years ago. Substance Abuse History: NEGATIVE Allergies: Nitroglycerin: chest pain Aspirin: Current Medications: Zocor 80mg Tablet 1 tab(s) po hs, Altace 10mg Capsules 1 cap(s) po qd, Insulin, Lispro (Analog rDNA) 100units/1ml Pen System, Disposable 25-30 U Sq AC meals, Norvasc 10mg Tablet 1 tab(s) po qd, Tenormin 100mg Tablet 1 tab(s) po qd, Heal with Steel Health Center. OBJECTIVE: Vitals: BP: 118/78 mm Hg; P: 46 bpm (regularly irregular); R: 12 bpm. Exams: GENERAL: moderately obese; well groomed; anxious; diaphoretic. EYES: lids and lacrimal system are normal in appearance; conjunctiva and cornea are normal. ENT: Oropharynx: normal dentition and gingiva; normal palate; normal oral mucosa. NECK: thyroid is non-palpable; jugular veins are normal. RESPIRATORY: normal respiratory rate and pattern with no distress; normal breath sounds with no rales, rhonchi, wheezes or rubs. CARDIOVASCULAR: normal rate and rhythm without murmurs; normal S1 and S2 heart sounds with no S3, S4, rubs, or clicks; carotids: 2+ amplitude, no bruits; abdominal aorta appears to be of normal size and is without bruits; femoral pulses: 2+ amplitude, no bruits; 2+ pedal pulses; no edema or significant varicosities. GASTROINTESTINAL: no masses or tenderness; no organomegaly. SKIN: no clubbing, cyanosis, ulcerations, or vascular skin lesions. MUSCULOSKELETAL: spine: no scoliosis, kyphosis, or other abnormal spinal curvatures; normal gait; grossly normal tone and muscle strength. NEUROLOGIC/PSYCHIATRIC: mental status: alert and oriented x 3; Mood/Affect: anxious. ASSESSMENT: E11.9 Type 2 diabetes, I10 Essential hypertension, E78.2 Mixed hyperlipidemia. PLAN: Type 2 diabetes LAB ORDERS: hgbA1C, fasting lipid profile, TSH, urinalysis, urine micro-albumin. MEDICATIONS: Over-the-counter medications recommended include aspirin. RECOMMENDATIONS: instructed in use of glucometer (check glucose before each meal), a daily aspirin, adherence to a 2200 calorie ADA diet, HgbA1C level checked quarterly, urine micro albumin test yearly, daily foot self-inspection, yearly dental exams, annual eye exams, need for yearly flu shots, and pneumovax vaccination every five years. FOLLOW-UP: Schedule a follow-up visit in three months. Orders: Collection of venous blood by venipuncture Handling and/or conveyance of specimen for transfer from the physician’s office to a laboratory Glycated hemoglobin Urinalysis, automated, without microscopy Dilated Eye Exam Lipid panel (total cholesterol, HDL, triglycerides) Thyroid stimulating hormone (TSH) Urine micro albumin, quantitative Other Orders: Collection of venous blood by venipuncture today Electrolyte panel (Na, K, Cl, CO2) Electrocardiogram, routine with at least 12 leads; with interpretation and report Electronically Signed: M, Jones, M.D. After review of the record provided, what discrepancy would a coder identify?