Chief complaint
follow up for depression
History
Patient, 56, presented with continued chronic fatigue and concentration issues. Reports regular physical activity, such as swimming at the YMCA up to one hour at a time, up to four times per week. Patient has had an 8-pound weight gain since last office visit. She notes daily activities such as walking in the park and going to the YMCA. She has modified diet and has consulted with nutrition services for evaluation. Reports adherence with healthy diet provided by dietetic services. Patient is in remission from colon cancer, not currently on medication administration of chemotherapy. She states that weight gain and continued fatigue may be the result of chemotherapy. Patient denies fever, chills, headaches, weakness and light-headedness.
Review of Systems
Constitutional: Negative.Negative for activity change, appetite change, and fatigue. Positive for unexpected weight change.
HENT: Negative
Eyes: Negative
Respiratory: Negative
Cardiovascular: Negative
Gastrointestinal: Negative
Endocrine: Negative
Genitourinary: Negative
Musculoskeletal: Negative
Skin: Negative
Allergic/immunologic: Negative
Neurological: Negative
Hematological: Negative
Psychiatric/behavioral: Has had decreased concentration but no dysphoric mood, self-injury, sleep disturbance or suicidal ideas.
Physical Exam
Blood pressure: 110/70
Temperature: 97.8 °F
Height: 5’ 7”
Weight: 307 pounds
Last menstrual period: 10/08/2012
BMI: 48.08 kg/m2
Constitutional: She is oriented to person, place and time. She appears well-developed and well-nourished. She is active. No distress.
HENT:
Head: Normocephalic
Right ear: Hearing, tympanic membrane, external ear and ear canal normal.
Left ear: Hearing, tympanic membrane, external ear and ear canal normal.
Mouth/throat: Uvula is midline, oropharynx is clear and moist and mucous membranes are normal.
Eyes: Conjunctivae, extraocular muscle and lids are normal. Pupils are equal, round and reactive to light.
Neck: Normal range of motion
Cardiovascular: Normal rate, regular rhythm, S1 normal, S2 normal and normal heart sounds.Exam reveals no gallop.
No murmur heard.
Pulmonary/chest: Effort normal and breath sounds normal. No respiratory distress. She has no decreased breath sounds. She has no wheezes. She has no rhonchi. She has no rales.
Abdominal: Soft. Bowel sounds are normal. She exhibits no distension. There is no hepatosplenomegaly. There is no tenderness. There is no rigidity, no rebound and no guarding.
Musculoskeletal: Normal range of motion.
Neurological: She is alert and oriented to person, place, and time.
Skin: Skin is warm and dry. She is not diaphoretic.
Psychiatric: She has a normal mood and affect. Her speech is normal and behavior is normal.
Assessment and plan
Other fatigue.
»CBC and differential TSH
Depression, unspecified
depression type.
»Refill trazodone HCL (trazodone oral)
Morbid obesity due to excess calories.
»Continue regular exercise and healthy diet
Documentation coding requirements
When documenting depression, include the following:
Major depressive disorder
Single (in partial or full remission) or recurrent episode
Mild, moderate or severe episode
With or without psychotic features
Bipolar disorder with current episode depressed (mild or moderate severity)
Mood disorder with or without major depressive-like episode
Adjustment disorder with depressed moodPostpartum depression
Code
F06.31
Mood disorder due to known physiological condition with depressive features
F06.32
Mood disorder due to known physiological condition with major depressive-like episode
F31.30
Bipolar disorder, current episode depressed, mild or moderate severity, unspecified
F31.32
Bipolar disorder, current episode depressed, moderate
F32.0
Major depressive disorder, single episode, mild
F32.1
Major depressive disorder, single episode, moderate
F32.2
Major depressive disorder, single episode, severe without psychotic features
F32.3
Major depressive disorder, single episode, severe with psychotic features
F32.4
Major depressive disorder, single episode, in partial remission
F32.5
Major depressive disorder, single episode, in full remission
F32.89
Other specified depressive episodes
F32.9
Major depressive disorder, single episode, unspecified
F33.0
Major depressive disorder, recurrent, mild
F33.1
Major depressive disorder, recurrent, moderate
F33.3
Major depressive disorder, recurrent, severe with psychotic symptoms
F33.8
Other recurrent depressive disorders
F33.9
Major depressive disorder, recurrent, unspecified
F43.21
Adjustment disorder with depressed mood
F53.0
Postpartum depression
Z13.31
Encounter for screening for depression
Z13.32
Encounter for screening for maternal depression
F34.1
Dysthymic disorder
Diagnosis code
R53.83
Other fatigue
F33.1
Major depressive disorder, recurrent, moderate
E66.01
Morbid (severe) obesity due to excess calories
Z68.42
Body mass index 45.0-49.9, adult