Musculoskeletal exam: The patient’s gait is normal, and she exhibits good muscle strength in upper and lower extremities, both proximally and distally. All joints are unremarkable with full range of motion and no evidence of synovitis.
Diagnoses:
- Raynaud’s phenomenon
- Rule out other autoimmune connective tissue disease
Plan: The patient is counseled regarding etiology, pathophysiology, symptoms, and prognosis for Raynaud’s phenomenon. Review measures to minimize Raynaud’s phenomenon are discussed, and the patient is provided with written information on Raynaud’s phenomenon. Laboratory studies are ordered to evaluate her for lupus or other autoimmune connective tissue disease, and the patient is started on nifedipine extended release.
The physician reviews actions and side effects of nifedipine with the patient, documents her findings in a written report, and sends it over to the primary care doctor.
How should this be coded?
