Reference no: EM131800433
AUDIT REPORT T1.1 OFFICE VISIT
LOCATION: Outpatient, Clinic
PATIENT: Andrew Vetter
PRIMARY CARE PHYSICIAN: Alma Naraquist, MD
CHIEF COMPLAINT: Recheck Diabetes
He has started doing PT to get his strength back and has noted improvement. He has not been having any chest pain or SOB. Past history of CAD. His DM has been variably controlled. He is taking Lantus 28 units in the evening and Humalog 12 units with meals. He is testing 2-4 times per day. He is having reactions around 3 PM about once a week. He does get a warning with the reactions. His sugars are highly variable at all testing times with high and low sugars. His evening sugars tend to be high, and he may overeat after supper. He continues to have numbness in the feet. There is no edema. His depression seems to be ok.
EXAM: Vitals:Weight is 180. Blood pressure is 120/70. Patient is alert and conversant.
He is near his ideal weight. There is no edema. The foot pulses are normal. The ankle and knee reflexes are normal. There is a slight decrease in the vibratory sensation. The chest is clear. Cardiac: The heart is regular with no murmur or S3. The abdomen is soft and nontender with no masses. The prostate is a little enlarged with no masses. The rectum is normal, and there are some small hemorrhoids noted. The stool is hemoccult negative.
IMPRESSION: 1) DM Type 1 with variable control, 2) Hemorrhoids, 3) CAD, stable.
PLAN: Anusol suppository bid prn and tub soaks. He may need to cut the noon Humalog by 2 units. See in 4 months with an HgbA1c.
T1.1:
SERVICE CODE(S): 99213_________________________________
ICD-10-CM DX CODE(S): E10.9____________________________
ICD-9-CM DX CODE(S): 250.01____________________________
INCORRECT/MISSING CODE(S):__________________________