Pt is established and returning for f/u of UTI.
HPI states: 66 yo fem. presents for f/u. H/O rt. lower pole simple cyst. UA today is negative. No UTI's over last year. No gross hematuria. Some lower abd pain before voiding. She does hold the urine at times. She denies constipation. Some incomplete bladder emptying at times. No changes in her health over the last year. Smokes 1 ppd. Nocturia x 1-2. PVR was 74 cc in clinic today.
ROS all other systems reviewed negative.
PFSH: Med/surgical history discussed, Family history discussed, alcohol/smoking discussed.
Exam: 7 elements with 0 in detail.
Impression and plan: 66 yo female with h/o rt. lower pole simple cyst which is stable. Renal US and urine cytology in one year (orders given for these). PVR was 74 cc. Smoking cessation discussed. F/U in one year.
Diagnoses: Renal cyst, acquired, left; Nocturia, Incomplete bladder emptying
What level of service can I give? I see the Incomplete bladder emptying addressed in this visit. The PVR was done to assess the post residual bladder content, but nothing was mentioned about it in the Impression and Plan, nor does he mention if 74 cc is normal, abnormal, okay by him, patient's baseline. I don't see anything about the Nocturia except that the patient has it. Can I give credit for 2 stable chronic illnesses?
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