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Please refer to the attachment to answer this . This… Image transcription textService Location Days or Units Principal Diagnosis Code Secondary Diagnosis Code(5) (list all applicable)… Show more Title: New Patient History and Physical Note:S:This new patient is a 35-year-old African-American female complaining of pain when she urinates. She is a divorced mother of three children ages 3, 5, and 9. She admits to having multiple sexual partners. She has not used any form of birth control since undergoing tubal ligation after the birth of her last child. She is not sure when her last menstrual period was because her menses have always been irregular. She thinks it was six weeks ago. Other than a recent URI, she states that she has been in good health. She has no other complaints.HISTORY OF PRESENT ILLNESS: Upon further ing I learned that this patient has been experiencing mild pelvic pain. She also says that she feels like she “always has to go”. She has been waking up four to five times at night to urinate for the last two nights. Although she has not taken her temperature, she has felt warm now and then over the past week, but she dismisses this as part of her recent cold symptoms. She denies blood in her urine, chills, or an increased sense of urgency to urinate. She has never had a urinary tract infection. She admits that she has been feeling fatigued and run down lately. Her job is becomingly increasingly stressful as she takes on more responsibility. When asked about her sexual history, she states that since the divorce she has been seeing a few guys she met in local clubs. She refers to this as “sowing her wild oats”. She says she married and had children at such a young age that she missed out on a lot of the experiences other women her age have already enjoyed. She loves her children but finds them overwhelming when they “act like little devils”.PAST MEDICAL HISTORY: Asthma, allergic rhinitisPAST SURGICAL HISTORY: Appendectomy age 13; Tubal ligation after the birth of her last childMEDICATIONS: Albuterol inhaler and Claritin, as often as she can get samples from the city clinicSOCIAL HISTORY: Patient works full-time as Law Enforcement Officer. She has not had regular annual gynecological exams or received any consistent health care. She drinks 2-3 beers per day, usually more on the weekends to help her deal with the stress of her children. She denies tobacco or illicit drug use.FAMILY HISTORY: Mother-diabetes type 2, hypertension. Father died last year of an Ml at age 60.0: PHYSICAL EXAMINATION VITALS:Temp 99.0F, Pulse 82, BP 127/84, Resp 16/min HEENT: Head normocephalic. PERRL. EOMI. oropharynx and TMs clear.NECK: Some nodal enlargement in the anterior cervical chain. Nontender. CV: S1, S2, RRR. No murmurs, rubs, or gallops appreciated. CHEST: Good air exchange. Slight expiratory wheezes over upper lung fields. No crackles. No CVA tenderness. ABDOMEN: 1BS. soft, ND. Diffuse lower quadrant tenderness. Marked supra pubic tenderness. No rebound or guarding. EXTREMITIES: Peripheral pulses strong and equal bilaterally. DTRs 2 upper and lower extremities. RECTAL: Not pertormed GYNECOLOGIC: Normal external genitalia without lesions. Cervix and vaginal wall appeared normal. No bacteria or fungus were seen on KOH prep and wet mount. GC and chlamydia cultures sent. Bimanual exam shows normal size uterus, no cervical motion tenderness, and no adnexal masses or tenderness.TEST RESULTS: UA dipstick positive for UTIDX: Urinary tract infection, pathogenic strains of E. coliRX: Septra p.o. one TAB b.i.d. x3TOTAL TIME SPENT WITH PATIENT: 30 minutesHealth Science Science Nursing Thiswas created fromOutpatient Coding (Toussaint)_CK1030.2.docx

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