Patient presents with a history of cerebrovascular accident (CVA), unspecified, with residual deficits.  The date of the original CVA is unclear, and the patient is unable to provide complete details regarding the event.  Medical history includes hypertension, hyperlipidemia, and a history of tobacco use.  Current symptoms include mild right-sided hemiparesis, impacting fine motor skills and gait stability.  Cognitive function appears intact, with no evidence of aphasia or dysarthria.  The patient denies current headache, dizziness, or vision changes.  Neurological examination reveals decreased muscle strength and slightly increased tone in the right upper and lower extremities.  Deep tendon reflexes are brisk on the right side.  Sensation is intact bilaterally.  Diagnosis of history of cerebrovascular accident, unspecified, is based on patient report and clinical findings.  Differential diagnoses considered included transient ischemic attack (TIA), peripheral neuropathy, and other neurological disorders.  Plan includes physical therapy to address gait and balance issues, occupational therapy for fine motor skill improvement, and continued management of hypertension and hyperlipidemia to reduce risk factors for future cerebrovascular events.  Patient education provided on stroke prevention, including medication adherence, lifestyle modifications, and recognizing stroke symptoms.  Follow-up appointment scheduled to monitor progress and adjust treatment plan as needed.  Coding considerations include ICD-10 code I69.9 for sequelae of cerebrovascular disease, unspecified, and appropriate CPT codes for evaluation and management, physical therapy, and occupational therapy services.  Medical billing should reflect the complexity of the patient's presentation and the services provided.