**Diagnosis: Urinary Tract Infection (UTI)**

Patient presents with complaints consistent with a urinary tract infection (UTI), including dysuria, urinary frequency, urgency, and suprapubic pain.  The patient denies fever, chills, flank pain, nausea, or vomiting.  Urinalysis demonstrates positive leukocyte esterase and nitrites, suggestive of a bacterial infection.  Microscopic examination reveals pyuria.  Based on the patient's symptoms and urinalysis findings, a diagnosis of uncomplicated urinary tract infection is made.  Differential diagnoses considered include interstitial cystitis and sexually transmitted infections.  Plan includes treatment with a course of oral antibiotics, increased fluid intake, and patient education regarding UTI prevention strategies.  Follow-up urinalysis will be performed to assess treatment response. Medical coding for this encounter may include ICD-10 code N39.0 for urinary tract infection, site not specified.  Common clinical documentation improvements for UTI include specifying the location of the infection (e.g., cystitis, pyelonephritis) and documenting antibiotic susceptibility testing if performed.  Accurate medical billing and coding practices are essential for proper reimbursement.



**Diagnosis: Type 2 Diabetes Mellitus**

Patient presents for follow-up management of type 2 diabetes mellitus.  The patient reports adherence to prescribed diet and exercise regimen.  Review of systems is notable for occasional polyuria and polydipsia.  Physical examination reveals no significant abnormalities.  Laboratory results demonstrate a hemoglobin A1c of 7.5%, indicating suboptimal glycemic control.  Current medications include metformin and glipizide.  The patient's diabetes management plan is reviewed and reinforced, emphasizing the importance of medication adherence, lifestyle modifications, and regular blood glucose monitoring.  Given the elevated A1c, the dosage of metformin is increased.  The patient is educated on the signs and symptoms of hypoglycemia and hyperglycemia.  Follow-up appointment is scheduled in three months to reassess glycemic control and adjust medication as needed.  ICD-10 code E11.9 for type 2 diabetes mellitus without complications is appropriate for this encounter.  Healthcare providers should document detailed information about diabetes management, including medication adjustments, patient education, and self-management goals. This information is crucial for accurate medical billing, coding, and improved patient outcomes.  Keywords for this diagnosis include diabetes management, insulin resistance, blood glucose monitoring, and diabetic complications.


**Diagnosis: Acute Bronchitis**

Patient presents with a chief complaint of cough, productive of yellow sputum.  Symptoms onset approximately one week ago and have progressively worsened.  The patient also reports chest tightness and shortness of breath with exertion.  Physical examination reveals diffuse wheezing and rhonchi on auscultation.  No fever is present.  The patient denies any history of asthma or other respiratory conditions.  Based on clinical presentation, a diagnosis of acute bronchitis is made.  Differential diagnoses include pneumonia and asthma exacerbation.  Chest x-ray is ordered to rule out pneumonia.  Treatment plan includes symptomatic management with cough suppressants, expectorants, and bronchodilators as needed.  Patient education focuses on rest, hydration, and avoidance of irritants.  Follow-up is recommended if symptoms do not improve within one to two weeks.  ICD-10 code J20.9 for acute bronchitis, unspecified, is appropriate for this encounter.  Accurate clinical documentation should include details of the patient's respiratory symptoms, physical examination findings, and treatment plan. This information supports appropriate medical billing and coding practices. Common related keywords include respiratory infection, cough treatment, and airway inflammation.