Family Medicine Note

SUBJECTIVE: - Reason for visit: Patient presents with persistent cough and shortness of breath. "I've been coughing for the past two weeks and it's getting harder to breathe, especially at night." History of presenting complaints: The cough started after a recent cold. No other therapies have been trialed. Previously seen at the local urgent care for similar symptoms last year. RELEVANT PAST MEDICAL HISTORY: - Past medical history: Asthma diagnosed in childhood, Hypertension - Medications: Albuterol inhaler, Lisinopril - Social history: Non-smoker, occasional alcohol use - Allergies: Penicillin REVIEW OF SYSTEMS: - Constitutional symptoms: Fatigue - Eyes: No symptoms - Ears, Nose, Mouth, Throat: Nasal congestion - Cardiovascular: No symptoms - Respiratory: Cough, Shortness of breath, No smoke exposure - Gastrointestinal: No symptoms - Genitourinary: No symptoms - Musculoskeletal: No symptoms - Integumentary (Skin): No symptoms - Neurological: No symptoms - Psychiatric: No symptoms - Endocrine: No symptoms - Hematologic/Lymphatic: No symptoms - Allergic/Immunologic: No symptoms OBJECTIVE: - Vitals: BP 130/85, HR 78, RR 20, Temp 37°C - Physical examination: Lungs - wheezing noted bilaterally, Cardiovascular - normal S1 S2, no murmurs - Investigations: Chest X-ray pending ASSESSMENT & PLAN: 1. Asthma exacerbation, J45.901 - Assessment: Likely diagnosis is asthma exacerbation - Differential diagnosis: Upper respiratory infection - Investigations planned: Chest X-ray - Treatment planned: Increase Albuterol inhaler use, start oral corticosteroids - Relevant referrals: None - CPT code for treatment rendered: 99213 2. Hypertension, I10 - Assessment: Hypertension, well-controlled - Treatment planned: Continue Lisinopril - Relevant referrals: None - CPT code for treatment: 99213 Visit CPT code: 99213 Dr. Thomas Kelly, MD Family Medicine Green Valley Clinic 1 November 2024