ASSESSMENT & PLAN:

ANNUAL VISIT

Encounter Diagnoses

Name

Primary?

• Encounter for general adult medical examination without abnormal findings

- Yes

• Elevated BP without diagnosis of hypertension

Tdap, twinrix. Declines prevnar

Had colonoscopy 2021. Repeat 2031

Discussed prostate cancer screening recommendations. Ptdeclines.

Declines hiv, hcv screening.

Reviewed cv risk factors, exercise.

Pt to send in HRA copy of lipids

Elevated bp w/o HTN.

Discussed DASH diet.

Return 2 months for nursing bp check.

QUESTION:

What should be the the primary diagnosis in this encounter?

Chief Complaint

Patient presents with

•Medication Management

SUBJECTIVE:

Acute complaints

 None

Chronic Condition Management

 # Anxiety/Depression

Medication: Lexapro 10mg daily

Complaint with medication

Denies any side effects

Dose was increased in April

Doesn't feel like much has changed

Feels like she just manages the anxiety

ASSESSMENT & PLAN:

1. Medication management

2. Generalized anxiety disorder

3. Brain fog

- Not stable

- Continue taking Lexapro 10mg daily

- EScitalopram (LEXAPRO) 10 MG tablet; Take 1 (one) tabletby mouth Daily.  Dispense: 90 tablet;Refill: 1

- Discussed starting Buspar 5mg TID for adjunct theraphy;Discussed risks/benefits and most common side

 effects

- Recommend further testing to ensure treating patient foranxiety only vs ADHD/Anxiety; Referral placed

- External Neuropsychology Referral

4. Breakthrough bleeding on Nexplanon

- Discussed IUD vs Depo

- Information sheet given; Unsure which birth control optionshe would prefer

- Advised patient to scheduled procedure visit when ready

QUESTION:

WHAT IS THE LEVEL OF MDM IN COPA COLUMN?

Chief Complaint

Patient presents with

• GI Problem

Very bad stomach ache after eating, every time

Interval History:

is a 16 y.o. female who presents for evaluation regardingthe following acute issue.

Patient presents with her mother for evaluation regardinglongstanding abdominal discomfort.  Shehas had problems for over a year.  Shehas been seen in several settings for this.

She reports a phenomenon where after eating she hasperiumbilical discomfort.  It can lastfor 5 to 30 minutes.  She often has abowel movement after eating but states that does not particularly help.  She tends to have 2 bowel movements aday.  She denies any nausea orvomiting.  Her weights been stable.  Appetites normal.  She has had no loose stools or diarrhea.  No fever chills or other constitutionalsymptoms.

In November she had full set of labs including lipase,urinalysis, CBC and CMP that were normal. She has tried Pepcid without improvement.  She feels that she eats a fairly healthy diet and that symptoms are triggered by healthy foods such as a salad or junk foods equally.

ASSESSMENT & PLAN:

Assessment & Plan

Abdominal pain, unspecified abdominal location

Orders:

•  US Abdomen RUQ;Future

•  XR AbdomenSupine/KUB; Future

I do not think repeating labs would be of benefit.  In the ER a right upper quadrant ultrasoundwas contemplated but never performed.  Ithink this would be of value to rule out biliary colic/gallstones although hersymptoms are not classic for this. Ultrasound order placed.

Will check KUB today.

I suspect her symptoms are related to functional constipation.  I suggested a 2-week trial of MiraLAX on a daily basis.  Family will report back on progress.

If symptoms or not improving consider trial of PPI and referral to gastroenterology.

QUESTION:

WHAT IS THE MDM LEVEL FOR COPA?

Reason for Visit

Edema

Bilateral leg/foot swelling. Patient states it maybe his new medication that he's taking for

Crohn’s  disease.

Assessment & Plan

Weight gain

2+ pitting edema

-Baseline weight 169 pounds. Today's weight in the clinic is 180 pounds.

- Patient has pitting edema right worse than left.  Concerns for acute renal failure, CHF, DVT, medication side effect amongst other differentials.

Patient should be seen in the ER he is at risk for organ failure which could lead to worsening outcomes.

QUESTION:

WHAT IS THE LEVEL OF COPA BASED ON DOCUMENTATION PRESENTED?

Chief Complaint

Patient presents with

• Back Pain

Patient reports that he has in a car accident on 05/31.

Patient states that the pain is in the lower left and travels down his leg to his knee.

HPI:  is a 58 y.o.male here to discuss below

ER follow-up–patient was in the ER May 31, 2025 after amotor vehicle collision.  Chest x-ray,

CT scan of the head, CT scan of the cervical spine, lumbarspine x-ray, right hand and wrist x-ray

were all negative for acute findings.  He was given fentanyl, Zofran, IV fluids, ketorolac in the ER. He was discharged home with a diagnosis of concussion.

He followed up with his PCP June 2, 2025.  He was referred to neurology for concussion.

Patient saw neurology June 11, 2025.  He was referred to physical therapy and started on gabapentin.

Assessment:

1. Acute left-sided low back pain with left-sided sciatica

Plan:

Assessment & Plan

Acute left-sided low back pain with left-sided sciatica

Suspect muscle strain/spasm from recent car accident leadingto lumbar radiculopathy/sciatica.

Lumbar spine x-raylast month was unremarkable

– Treat as below with meloxicam and cyclobenzaprine and homeexercises

– Refer to PT in 2 weeks if not improving