Evaluation and Management Coding Practice: Ginny Tallman is a 73-year-old female who is followed in the Medical Clinic for COPD. Her medications include Theo-Dur 300 mg by mouth daily in the morning. History of present illness reveals that she seems to have adequate control of her bronchospasm using this medication. She also uses an albuterol inhaler two puffs p. o. q6h. She has no recent complaints of acute shortness of breath and no chest tightness. She has a chronic, dry cough, productive of scanty sputum. At this time, she is complaining of shortness of breath. PE reveals an elderly female in no real distress. BP in the left arm, sitting, is 110/84, pulse 74 per minute and regular, respiratory rate 12 per minute and somewhat labored. Lungs reveal scattered wheezes in both lung fields. There is also noted an increased expiratory phase. Cardiovascular exam reveals no S3, S4, or murmurs.

The impression is COPD with asthmatic bronchitis. The patient will have present medications increased to Theo-Dur 300 mg by mouth daily in the morning and 400 mg by mouth each evening. She should receive follow-up care in the clinic in approximately two months' time.

E/M category/subcategory: Office or Other Outpatient Services, Established Patient

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problem focused

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