The physician provided a service to a new patient in a custodial care center. The patient is a paraplegic who has pneumonia of moderate severity. Patient has no other complaints aside from cough related to pneumonia. After taking the patient’s history, the physician performed an expanded problem-focused examination. The examination focused on the respiratory and cardiovascular systems, based on the patient’s current complaint and past history of tachycardia. The medical decision making was of low complexity.
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