Nursing Homework week 4, Clinical

Case Log 3: Annual Check-Up with Abnormal Liver Enzymes

· Patient Demographics: Age: 45 years, Male, Hispanic Insurance: PPO

· Reason for Visit: Annual exam

· Chief Complaint: "Here for my yearly check-up."

· Type of H&P: Comprehensive

· Clinical Notes (SOAP): A 45-year-old male presents for an annual physical. Denies acute complaints. Vitals stable. Physical exam unremarkable. Routine labs showed elevated hepatic enzymes (ALT/AST). Patient denies alcohol use, medications, or supplements. The plan includes repeat LFTs, a hepatitis panel, and an abdominal ultrasound. Counseled on lifestyle, avoiding hepatotoxic substances, and follow-up in 1 month.

· ICD-10 Codes:

· Z00.00 — Encounter for general adult medical exam without abnormal findings

· R74.01 — Elevation of liver transaminase levels

· CPT Codes:

· 99396 — Preventive visit, established patient, age 40–64

· 80053 — Comprehensive metabolic panel