This is a progress note from the office records of a physician’s office

This is a progress note from the office records of a physician’s office: Chief Complaint: Chest pains in a 44-year-old male HPI: Patient indicates that he woke up this morning with what he thought was indi- gestion but as the morning progressed he began to have some intermittent chest pains. He comes to the office for check-up. Past Medical History: Patient has mild open angle glaucoma, mild hypertension. and DJD. He does smoke a pack of cigarettes per day. in light of his family history. l have repeatedly suggested that the patient attempt a smoking cessation regime. I have offered prescription mode but patient refuses. Family History: Patient’s father died at age 43 of myocardial infarction. His older brother has had one minor Ml at age 51. Vital Signs: BP 163MB; pulse 89; respirations 17. Physical Examination: HEENT: Glaucoma, diagnosed eight months ago, is in control. He iast saw his ophthalmologist just about three weeks ago. I will continue to monitor in between visits with the specialist. Pulmonary: Chest is clear to percussion and auscultation. No raise or rhonchi heard. Hiatal hernia noted. Abdomen: Obese. No gross hepatosplenomegaly. Bowel sounds are normal. Extremities: Pedal edema in the lower extremities. There did not appear to be any lesions or open wounds on the lower extremities. Patient complained of some pain in the right knee. He has a history of a right knee replacement some 10 years ago. | see no obvious abnormalities with the knee but if it continues to cause him discomfort he should see an orthopedist. Cardiovascular: Heart sounds were regular. No murmurs or ectopic beats heard. Plan: Because of the patient’s hypertension and family history of myocardial infarcticns. the chest pains are extremely worrisome. I have arranged for the patient to have a cardiac catheterization today. He was instructed to report to the hospital immediately. What codes would be recorded for this office visit? |CD-10-CM Code(s):

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