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jaydenrenee111902
jaydenrenee111902
17.09.2019 • 
Biology

This patient is seen in the clinic at the request of dr. jones for evaluation of suprapubic pain. patient is a 22-year-old black female g1 p0, lmp 12/20/xx, edc 10/16/xx by 14-week ultrasound taken on 4/16/xx, 18 weeks with twin gestation. presents with complaint of suprapubic sharp to mild pain with onset 2 months ago. pain has become progressively worse. patient has been seen by dr. jones for this pregnancy and has also been seen by dr. smith for this current complaint 2 weeks ago. patient denies urgency and frequency of nocturia, denies hematuria, and denies discharge. labs: cbc and urinalysis performed. allergies: none. past medical history: genital wart 1986. past surgical history: wart removed by laser 1986. social history: no smoking, illicit drugs, or alcohol.pe: during an expanded problem-focused examination, the heent was found to be normal. fht: a 148, b 146. heart: normal. lungs: cta. abdomen: gravid 20 cm. slight tender suprapubic region. vaginal exam: closed cervix, thick, long; no discharge. extremities: negative for edema; ua loaded with bacteria and wbc.impression: 1. iup at 18 weeks with twin gestation. 2. acute uti (the mdm was straightforward).recommendation: keflex, 500 mg, and follow-up with dr. jones.cpt code:

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