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CC: Shortness of breath
History: A 62-year-old female returns to a family practice having shortness of breath for the last week. It has been two years since her last visit to the practice. She also has nausea, diaphoresis, chest pressure.
Past History: Celebrex® for her arthritis.
Hysterectomy 1 year ago.
Social History: Smoker-No Alcohol-No
Allergies: Penicillin
PHYSICAL EXAM
Vital Signs: BP 195/95 sitting, left arm
General/Constitutional: Mild distress. Some diaphoresis.
Nose/Throat: Mucous membranes normal. Oropharynx appears normal. No mucosal lesions.
Neck/Thyroid: Supple, without adenopathy or enlarged thyroid.
Respiratory: Shallow breathing, no wheezing.
Cardiovascular: Unequal pulses in both arms. Abnormal heart sounds heard.
EKG ordered.
Assessment/Plan
Severe exacerbation of congestive heart failure
Patient is sent to the hospital to be admitted. Will send hospital orders to
start her on IV, order chest X-ray and CBC.
A. 99202
B. 99215
C. 99204
D. 99214