Question 1
Which of the following is NOT a subjective medical history question?
◦ What is your date of birth?
◦ What prescription medications are you currently taking?
◦ What were you doing when the problem was first experienced?
◦ What over-the-counter medications are you currently taking?
Question 2
OFFICE VISIT
S: This established patient comes in stating that her legs are swollen and tender to touch. She has had a little bit of shortness of breath and just has not been feeling normal. PAST MEDICAL HlSTORY: Congestive heart failure, hypertension, and gastritis. MEDICATlON: Warfarin, potassium, Lasix, Clonapam, metoprolol, Dilantin, and orneprazole. ALLERGIES: PENICILLIN.
O: VITAL SIGNS: As noted. O
2 saturations 88%. GENERAL: Alert and oriented. HEENT: Unremarkable. LUNGS: There are a few crackles in the lungs. HEART: Regular rate and rhythm. EXTREMITIES: There is 2+ edema. LABORATORY/DIAGNOSTIC: Normal CBC. Comprehensive panel shows a BUN that is slightly elevated, otherwise unremarkable. Her BNP is high at 442.
A: Congestive heart failure, peripheral edema
P: We will have her double up her Lasix taking 2 a day and potassium 2 per day for the next 5 days and then go back to her regular medications. If she is still having swelling problems, she is to let us know.
ICD-9-CM diagnosis code(s): _____________________
ICD-10-CM diagnosis code(s): _____________________
CPT code(s) with modifier, if applicable: _____________________
The nurse needs to note the source of the patient health history
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