Nursing Homework week 8, Clinical

Patient Demographics:

· Age: 52 years

· Biological Sex: Male

· Race: Hispanic

· Insurance: PPO

· Referral: No referral

Reason for Visit: New consult Chief Complaint: “I have been feeling very tired and thirsty lately.” Type of H&P: Comprehensive Type of Decision Making: Moderate complexity Time with Patient: 35 minutes

Clinical Notes: Patient presents with polyuria, polydipsia, and fatigue for the past few weeks. Denies chest pain, shortness of breath, or weight loss. Vitals: BP 138/84 mmHg, HR 82 bpm, BMI 31.2. Physical exam unremarkable. Random glucose 248 mg/dL, HbA1c 7.9%. Assessment: Newly diagnosed Type 2 Diabetes Mellitus. Plan: Educated patient on diet and exercise, started Metformin 500 mg PO BID, recommended nutrition referral, ordered fasting labs and follow-up in 3 months. Patient verbalized understanding.

ICD-10 Codes:

· E11.9 – Type 2 Diabetes Mellitus without complications

· Z71.3 – Dietary counseling and surveillance

· Z68.31 – BMI 31.0–31.9, adult

CPT Billing Codes:

· 99204 – Office visit, new patient, moderate complexity

· 36415 – Collection of venous blood

Medications:

· Metformin 500 mg PO BID (new prescription)

Social Problems Addressed:

· Nutrition/Exercise

· Prevention

· Education/Language