[Answered]: New Patient History and Physical Note: CHEIF…

New Patient History and Physical Note: CHEIF COMPLAINT: “I’ve been short of breath this past week at school, and the school nurse suggested I see my doctor right away. He sent me to see you.” HISTORY OF PRESENT ILLNESS: Mathew is a 17 year old senior in high school who was referred here from his primary care physician. He was in a normal state of health for the past 17 years but over the past week he has become very tired and short of breath while awake and at night. This has progressed to the point where he can no longer talk without gasping for air. Yesterday, he experienced a slight pressure in his chest and was lightheaded with a “flip flop feeling” which happened when he participated in gym class. Resting with two pillows to elevate his head relieved this pressure. The school nurse was called to assess Mathew’s health, she dismissed him from class so that he could see his PCP immediately. ASSESSMENT: 17-year-old male with hypertrophic cardiomyopathy requiring relief of his shortness of breath. PLAN: Admit to Cardiac unit for medical observation, evaluation, and initiate treatment of hypertrophic cardiomyopathy and shortness of breath. TOTAL TIME SPENT WITH PATIENT: 65 minutes FIND ICD-10-CM AND CPT CODE