Herpes gestationis, second trimester

This is the sample :

O26.42 | Herpes gestationis, second trimester

Patient is a 30 year old female present the clinic for follow up on lab results and also for further testing. Patient has no allergy, no history of STD’s, G1P0, and LMP 02/18, usually period is regular last about 5 days but not heavy, menarche at 11. Patient denied any signs of infection or vaginal bleeding at this time.

Patient stated that her early pregnancy symptoms are gone. Patient is 5’3 last weight 147 pounds today she weight 150, V/S today are WNL/stable, pain 0. Patient had all her STDs done during her first trimester (HIV, herpes, chlamydia, gonorrhea, syphilis, BV, trichomoniasis) tested and all came back negative and non-reactive, Rh testing positive, pap test normal negative for HPV and G&H. Patient had all STDs repeated and is here for result and also follow up. Plan: herpes type came back positive but everything else are negative, patient denied any symptoms.

Ultrasound done in office and 1 fetal noted to be moving with regular heart beat (142), patient education on herpes infection, signs to report and if become symptomatic prior vaginal birth C-section may be consider and also med like acyclovir may be prescribe to be taken at home prior labor and she stated to understand.

O00.1 | Tubal pregnancy

O00.2 | Ovarian pregnancy

O00.8 | Other ectopic pregnancy

O00.9 | Ectopic pregnancy, unspecified

N94.0 | Mittelschmerz

N94.1 | Dyspareunia

N94.2 | Vaginismus

N94.3 | Premenstrual tension syndrome

N94.4 | Primary dysmenorrhea

N94.5 | Secondary dysmenorrhea

N94.6 | Dysmenorrhea, unspecified

N94.810 | Vulvar vestibulitis

N94.818 | Other vulvodynia

N94.819 | Vulvodynia, unspecified

N94.89 | Oth cond assoc w female genital organs and menstrual cycle

N94.9 | Unsp cond assoc w female genital organs and menstrual cycle

Last Updated on February 11, 2019 by EssayPro