S: This established patient comes in stating that her legs are swollen and tender to touch. She has had a little bit of shortness of breath and just has not been feeling normal. PAST MEDICAL HlSTORY: Congestive heart failure, hypertension, and gastritis. MEDICATlON: Warfarin, potassium, Lasix, Clonapam, metoprolol, Dilantin, and orneprazole. ALLERGIES: PENICILLIN
O: VITAL SIGNS: As noted. O2 saturations 88%. GENERAL: Alert and oriented. HEENT: Unremarkable. LUNGS: There are a few crackles in the lungs. HEART: Regular rate and rhythm. EXTREMITIES: There is 2+ edema. LABORATORY/DIAGNOSTIC: Normal CBC. Comprehensive panel shows a BUN that is slightly elevated, otherwise unremarkable. Her BNP is high at 442.
A: Congestive heart failure, peripheral edema
P: We will have her double up her Lasix taking 2 a day and potassium 2 per day for the next 5 days and then go back to her regular medications. If she is still having swelling problems, she is to let us know.
ICD-9-CM diagnosis code(s): _____________________
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ICD-10-CM diagnosis code(s): _____________________
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CPT code(s) with modifier, if applicable: _____________________
What will be an ideal response?
Answers:
ICD-9-CM diagnosis code(s): 428.0, 782.3
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ICD-10-CM diagnosis code(s): I50.9, R60.0
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CPT code(s) with modifier, if applicable: 99214
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