CHART NOTE CC: This Established Patient Presents to the Office Today with Today

question 8

Short Answer

CHART NOTE
CC: This established patient presents to the office today with complaints of rectal bleeding and itching of 2 weeks' duration.
OBJECTIVE: This is a 50-year-old male in apparent good health. His BP is 119/78. Rectal examination showed a grade 1 hemorrhoid in the 2 o'clock position approximately 2 cm across. The area around the hemorrhoid was slightly inflamed and a small amount of blood was noted.
ASSESSMENT: Hemorrhoid.
PLAN: Discussed conservative treatment options with the patient and explained surgical option. He wants to try the more conservative approach of stool softeners, warm and sitz baths. I discussed with him the importance of improved bowel habits. He is to return for a recheck in 2 months. The medical decision making was of straightforward complexity.
CPT Code: ____________________

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