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Case 1: Chapter 8 – Delores Dauphine (Question is located at the bottom of case)

FAMILY DOCTORS ASSOCIATES 

123 MAIN STREET • ANYTOWN, FL 32711 • 407-555-1234 

PATIENT: 

DAUPHINE, DOLORES 

ACCOUNT/EHR #: 

DAUPDO001 

DATE: 

02/05/18 

Attending Physician: 

James Healer, MD 

 

S: Pt is a 15-year-old female seen in our office for a physical exam as a requirement for her admission to the Marlberry School for Girls.

O: BP 130/95 P normal R normal Ht 5′0″ Wt 175 lb. HEENT: unremarkable. Heart and lung sounds unremarkable. Pt is morbidly obese. Elevated blood pressure noted. Extensive discussion with pt regarding her weight, the health risks associated with obesity, and the options available to her.

A: Obesity, benign essential hypertension

P:  1. Complete school admission form 

 2. Referral to nutritionist for diet and exercise regime 

 3. Return for checkup in 6 months

James Healer, MD

JH/mg D: 02/05/18 09:50:16 T: 02/08/18 12:55:01

There are four ICD-10-CM codes you should assign to this case. What is one of those codes? And E/M code for this case ?

SCIENCE
HEALTH SCIENCE
NURSING
MCCG 240

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