A 62-year-old male patient returns to the office for a follow-up visit for his gout. The patient’s present uric acid level is at 4.0. He was taken off indapamide because it was increasing his uric acid. He is now taking allopurinol at 450 mg per day. His left ankle has no pain but has mild swelling. There is no tenderness to the left ankle or foot. He is only taking colchicine when he has acute flare attacks. The patient is now on a low-purine diet and is under treatment for squamous cell cancer on his nose and on his right arm near a tattoo. He will not receive chemotherapy until May of this year. He still takes gabapentin for facial neuropathy. He will be in Florida from February until May.
Past Family History:
- Father also suffered with gout but is no longer living.
- Father had squamous cell cancer.
Review of Systems:
- Constitutional: Negative for chills, pallor, fatigue, fever, weight gain/loss
- Neurologic: Negative for weakness
- Endocrinology: Negative for malaise, night sweats
- Respiratory: Negative for cough, dyspnea, chest pain (respiratory), wheezing
- Gastrointestinal: Negative for anorexia, nausea,
- emesis, hematemesis, diarrhea, constipation, melena, abdominal pain, dysphagia, reflux, indigestion/heartburn
- Musculoskeletal: Negative for rheumatologic manifestations, back pain, myalgias. Positive for joint and bone symptoms—left ankle pain, complains of swelling, severity mild
Physical Exam:
- General/Constitutional: Vital signs: blood pressure (BP) systolic–122, BP diastolic–80; Weight (lbs.)–216.00; Temp (F)–97.2, Pain Score 3/10; well nourished, well developed
- Respiratory: Chest symmetric, lungs clear to auscultation, no cough
- Psychological: Patient mood is good, no acute distress
- Musculoskeletal: Left ankle is positive for swelling, decreased range of motion (ROM); left foot has mild swelling, no pain, mildly reduced ROM; there are zero tender joints; there is one swollen joint; no tenderness or warmth; patient can bear full weight without pain.
Medical Decision Making:
- Radiologic Procedures: Reviewed left foot X-ray heel spur, soft tissue swelling from a prior visit
- Laboratory Studies: Reviewed urinalysis complete, uric acid, C-reactive protein, Sed Rate by Mod Wet, CMP, CBC (includes DIFF/PLT) from the previous visit.
Assessment/Plan:
- The patient’s gouty arthopathy is improved. Patient’s present uric acid is 4.0. Allopurinol OD and takes colchicine 0.6 OD/BID with acute flare. I will have the patient follow up in three weeks, prior to leaving for Florida. Emphasized the importance of daily adequate hydration and maintaining a low-purine diet. I discussed with the patient different options for a diet and exercise plan. I will order new labs. Also, stressed importance of patient calling for an appointment if he has an acute flare so I can aspirate the fluid from the joint for a crystal analysis. The total time for the visit was 30 minutes and more than 50% of the visit was spent on counseling the patient on a diet and exercise plan.
How should this visit be coded? click here for the answer
