Assign the ICD-10-CM code using the ICD-10-CM manual. Outpatient Office Visit Patient Case Number: O

Assign the ICD-10-CM code using the ICD-10-CM manual. Outpatient Office Visit Patient Case Number: OPOV20-Chisholm, Andrea (established pt) Patient Name: Andrea Chisholm DOB: 02-14-77 Sex: F Date of Service: 05-11-XX Physician: Mary Schaeffer, MD Chief Complaint: Annual Gynecological Exam History of Present Illness: This is divorced 27-year-old Caucasian/White female who presents today for her annual gynecological exam. Her menses are absent secondary to Aygestin. She describes her menstrual flow as none and has had occasional spotting. She denies dysmenorrhea. Her LMP was January of last year. She is using Aygestin for endometriosis for treatment of pelvic pain. She is sexually active and uses nothing for contraception. She reports no problems with intercourse. Her last PAP was approximately one year ago and was normal. She reports no breast symptoms. Her last mammogram was 1 year ago and was normal. There is no family history of breast cancer. Since her last annual GYN exam 1 year ago, she has had no significant changes in her general health history. The patient does not smoke. She denies any sexual risk factors Today’s assessment shows that the patient has a normal BMI. Dietary and exercise recommendations were provided. The patient is not pregnant. Past Medical History: Endometriosis Medications: Aygestin Allergies: Amoxicillin and Ceclor Family Medical History: Ovarian cancer, high cholesterol Reproductive History: Menstrual Age Menarche: 13 Flow: Heavy Method of Birth Control: OCPs Cycle Interval (Days): 30 LMP: January of last year Clots?: Yes Menses Duration: 7 Office Pregnancy Test: No Breakthrough Bleeding?: Yes Pregnancy Summary Total Pregnancies: 3 Ab Induced: 0 3/1/2021 OPOV20ChisholmAndrea https://myahima.brightspace.com/content/enforced/6681-VLAB_STUDENTPROTO/PatientCaseScenarios/Outpatient_Office_Visit/OPOV20ChisholmA… 2/4 Multiples: 0 Full Term: 2 Ab Spontaneous: 1 Living: 2 Premature: 0 Ectopics: 0 Social History: Review of Systems: Constitutional Denies: Fatigue, night sweats, weight loss, weight gain HENT: Denies headaches Breasts: Denies lumps, tenderness, swelling, redness, nipple discharge Gastrointestinal: Admits abdominal pain, denies: diarrhea, constipation, blood in stools, hemorrhoids, problems with bowel movements Genitourinary: Denies urgency, frequency, dysuria, nocturia, hematuria, Incontinence, dyspareunia, irregular menses, dysmenorrhea, menorrhagia, vaginal discharge Endocrine: Denies polyuria, polydipsia, cold intolerance, heat intolerance, hot flashes/night sweats Psychiatric: Denies anxiety, depression, difficulty sleeping Vitals: BP-130/80, Temp-98.6, Wt-152lbs Ht: 5’7″ BMI: 23.8 Physical Examination: Constitutional ● Appearance: well-nourished, well developed, alert, In no acute distress HENT ● Head: normocephalic, atraumatic ● Face: face within normal limits, no sinus tenderness on palpation, no hirsutism present, parotid glands within normal limits Neck ● Inspection/Palpation: normal appearance, no masses or tenderness ● Lymph Nodes: no lymphadenopathy present ● Range of Motion: neck supple with full range of motion ● Thyroid: gland size normal, nontender, no nodules or masses present on palpation Chest ● Respiratory Effort: breathing unlabored ● Auscultation: normal breath sounds, no rales, no rhonchi ● Inspection of Chest: no lesions or traumatic injuries, no scars present 3/1/2021 OPOV20ChisholmAndrea https://myahima.brightspace.com/content/enforced/6681-VLAB_STUDENTPROTO/PatientCaseScenarios/Outpatient_Office_Visit/OPOV20ChisholmA… 3/4 Cardiovascular ● Heart: ● Auscultation: regular rate, normal rhythm, no murmurs present Breasts ● Inspection of Breasts: breasts symmetrical, no skin changes, no discharge present, no skin retraction present ● Palpation of Breasts and Axillae: no masses present on palpation, no breast tenderness ● Axillary Lymph Nodes: no lymphadenopathy present Gastrointestinal ● Abdominal Examination: abdomen nontender to palpation, normal bowel sounds, tone normal without rigidity or guarding, no masses present, umbilicus without lesions ● Liver and spleen: no hepatomegaly present, liver nontender to palpation ● Hernias: no hernias present Genitourinary ● External Genitalia: normal appearance for age, no discharge present, no tenderness present, no inflammatory lesions present ● Vagina: normal vaginal vault without central or paravaginal defects, no discharge present, no inflammatory lesions present, no masses present ● Bladder: nontender to palpation ● Urethra: ● Urethral Body: urethra palpation normal, urethra structural support normal ● Urethral Meatus: no erythema or lesions present ● Cervix: appearance healthy, no lesions present, nontender to palpation, no bleeding present ● Uterus: nontender to palpation, no masses present, position: anteflexed, mobility: normal ● Adnexa: no adnexal tenderness present, no adnexal masses present ● Perineum: perineum within normal limits, no evidence of trauma, no rashes or skin lesions present ● Anus: anus within normal limits, no hemorrhoids present ● Rectal: normal sphincter tone, no hemorrhoids present, no rectal masses present ● Inguinal Lymph Nodes: no lymphadenopathy present Musculoskeletal ● Pelvis: • Inspection/Palpation: no pelvic bony or muscular tenderness • Stability: no instability present Skin ● General Inspection: no rashes present, no lesions present, no areas of discoloration ● General Palpation: no abnormalities on palpation, no tenderness to palpation Neurologic/ Psychiatric 3/1/2021 OPOV20ChisholmAndrea https://myahima.brightspace.com/content/enforced/6681-VLAB_STUDENTPROTO/PatientCaseScenarios/Outpatient_Office_Visit/OPOV20ChisholmA… 4/4 ● Mental Status: • Orientation: grossly oriented to person, place and time • Mood and Affect: mood normal, affect appropriate Assessment 1. Gynecological Exam 2. Endometriosis 3. Amenorrhea secondary to BCP

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