OFFICE VISIT PATIENT: Milly Mortonson
PHYSICIAN: Donald Grossman, MD
CHIEF COMPLAINT: Hypothyroidism
SUBJECTIVE: Milly is a 39-year-old established patient who is a married white female with a history of hypothyroidism.
The TSH level done in May of 2018 was mildly elevated at 12.37. Since then, the patient has been taking an increased dose
of Synthroid at 0.125 mcg daily. Except for her weight, she reports that she is feeling quite well. She is frustrated that she
has gained weight over the summer.
OBJECTIVE: Weight is 180 pounds. No other examination is done today during this problem-focused encounter.
ASSESSMENT:
1. Hypothyroidism, euthyroid on treatment
2. Weight gain
PLAN: She will continue on brand name Levothyroid (this is the brand carried by the hospital) 0.125 mcg daily. The patient
was given some information on weight loss and walking program put on through the Public Health Department. Medical
decision making at a straightforward level. Return clinic visit p. r.n.
Which ICD-10-CM codes are assigned?
O A. R63.5, E23.0
O B. E23.0, R63.5
O C. E03.9, R63.5
O D. R63.5, E03.9