Problem:
An 86-year-old male here in the office in follow up. Having trouble with neuropathic symptoms, numbness, tingling, burning in his feet. He tried Nortriptyline. It did not seem to help much at all. Still on simvastatin 20 for hyperlipidemia, aspirin for his history of old MI, and albuterol for COPD. Patient having no coughing, or shortness of breath right now continue with Symbicort. No chest pain or palpitations. No back pain. OBJECTIVE: He is afebrile. Blood Pressure is 128/74. LUNGS: Clear. CARDIAC EXAM: Regular rate and rhythm. ASSESSMENT AND PLAN:
1. Peripheral neuropathy. Nonresponsive to Nortriptyline. Try Lyrica 50 mg. If causes dizziness advised him to stop. The only other option would be to try Cymbalta or Neurontin.
2. Hyperlipidemia. Continue Simvastatin.
3. Gastroesophageal Reflux disease. Continue Rantidine.
4. Healthcare maintenance. Flu shot given. Follow up two weeks. What diagnosis codes are reported?