[Expert Solution]: Patient Name: Kearns, Louis MR# 1011256…

Patient Name: Kearns, Louis MR# 1011256 Date of Service: 06/07/YYY Clinic Note: This 65-yar-old patient returns today for a follow up regarding headaches. He was referred March 1 for C7-L1 facet injections. He states headache pain has resolved to a tolerable level since the injections. He also complains of pain in his lower back. Past medical History: BPH, Cervicothoracic disc disorder, unspecified with cervicogenic headaches. Medications: Flomax and Proscar. Multivitamin and Ibuprofen Allergies: NKDA, NKA Review of Systems: HEENT, NECK, HEART, LUNGS, EXTRMITIES unremarkable. SKELETAL: DDD Cervical through lower spine. Impression: Enlarged prostate with current Rx. Other intervertebral disc degeneration, lumbosacral region causing pain in L5-S1. Headache, unspecified. Plan: Referral to orthopedic consult for DDD pain in L5-S1. Tramadol 50 mg for low back pain. Continue OTC remedies for headache. Continue current Rx for BPH. Requires three codes: When sequencing this case, note the reason the patient is returning for follow up, this is your first-listed code. . Identify the additional complain for and finally identify the condition that is in the patient history and currently under Tx via Rx