Icd 10 code for thyromegaly unspecified

Patient Information

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Ethnicity of Patient:

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Additional Information

Date:

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Comments:

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Chief Complaint:

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Plan of Care:

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CPT/ICD-10:

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SEE FOLLOWING EXAMPLE

Student Comments:

THIS IS A 64 YEAR-OLD FEMALE PRESENT TO CLINIC COMPLAINING OF ABDOMINAL PAIN AND UNCONTROLLED HYPERTENSION. GENERAL: OBESE HISPANIC FEMALE WITH LIMITED DISTRESS DUE TO ABDOMINAL PAIN HEENT: HEAD IS NORMOCEPHALIC, ATRAUMATIC, PUPILS EQUAL, ROUND, REACTIVE TO LIGHT, ANICTERIC SCLERAE. NECK: SUPPLE, NO JVD, NO CAROTID BRUIT, NO THYROMEGALY. CHEST: SYMMETRY WITH SLIGHLY DIMINISHED BREATH SOUNDS AND SCANTY RALES, NO RHONKI, NO WHEEZES CARDIOVASCULAR: PATIENT NOTICED TO BE SINUS BRADYCARDIC. S1,S2 HEARD. NO MURMURS, NO RUBS OR GALLOPS. ABDOMEN:FULL AND OBESE. NORMOACTIVE BOWEL SOUNDS. NO ORGANOMEGALY. NO CVA TENDERNESS. NO ASCITES. NO GUARDING. EPIGASTRIC PAIN TO PALPATION. EXTREMITIES. NORMAL ROM, NO JOINT INDURATION OR SWELLING. NEUROLOGIC: PATIENT IS CONSCIOUS, ALERT, ORIENTED TO TIME, PLACE AND PERSON. CRANIAL NERVES II-XII GROSSLY INTACT WITH NO FOCAL NEUROLOGICAL DEFICIT. MOTOR AND SENSORY MODALITIES APPEAR GROSSLY INTACT. SKIN: PATIENT DOES NOT HAVE ANY OVERT OR INTEGUMENTARY CHANGES. V/S. TEMP: 97.6, HR: 55, RR 20, BP: 196/88, O2 SAT:96 RA PAIN LEVEL 8/10.

Patient Age:

64 Years

Patient Sex:

F

Patient Ethnicity:

Hispanic or Latino

Chief Complaint:

ABDOMINAL PAIN & UNCONTROLLED HYPERTENSION

PLAN OF CARE:

UNCONTROLLED HYPERTENSION: WILL TREAT ABDOMINAL PAIN FIRST CHECK BP MANUALLY ON BOTH SIDES TITRATED UP BB,CCB, CLONIDINE TO TARGET BP SYSTOLIC 140. ABDOMINAL PAIN: COULD BE GASTRITIS, VS PANCREATITIS VS ACS MORPHINE AS NEED, PPI CT ABDOMEN AND PELVIS W/O CONTRAST ORDERED R/O ACS WITH EKG AND TROPONIN LIPASE LEVEL. HEMATOLOGY BASIC LABS CHEMISTRY COMPREHENSIVE LABS

CPT/ ICD code: I16. 0 is a billable/specific HYPERTENSIVE URGENCY/R10. 9 - Unspecified abdominal pain. ICD-10-CM.

CPT should be based on diagnostic test.

Note: I need 105 patient encounters. You may come with your own chief complaint and you may also refer to list attached. Patient age should be 18 or older

this section should include General information.past medical history,Past surgical hx

Allergies, home meds, vital signs.