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