CHART NOTE CC: Dizziness

question 54

Short Answer

CHART NOTE
CC: Dizziness
SUBJECTIVE: This 46-year-old female established patient presents today reporting feeling ill yesterday, and she has developed some dizziness. She feels like things stick in her throat and that her throat is "sticky." She has a past history of hypothyroidism and taking Synthroid 0.125 mg q day. Her last TSH was last year and the level appeared to be normal at 0.49.
OBJECTIVE: The patient appears to be in good health and in good spirits. Her BP is 120/81. Afebrile. HEENT normal. Neck is supple. No palpable masses are noted. No thyromegaly, tenderness, or nodes. TSA is elevated at 9.9.
ASSESSMENT: Hypothyroidism (MDM was low).
PLAN: Increase Synthroid to 0.15 mg q day. Recheck in 2 months.
CPT Code: ____________________

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