You are coding this office visit, which occured on 4/10/2021.
Patient: Jan Doe
Provider: Jane Smith, MD - Primary Care
Chief Complaint: Abdominal Pain
This Medicare Part B patient lives in Virginia and is seen by me in our Virginia office location and was last seen 6 months ago. Patient is a 65-year-old female, who comes in complaining of episodic pain in her right lower quadrant since Monday, with diarrhea off and on over the last week. She has had a couple of episodes of vomiting and overall feeling nauseated. She has tried over the counter medications for diarrhea Imodium and Pepto Bismol for stomach discomfort, nothing much helped. The pain has woken her up at night, and she complains of being tired all the time. She denies fever, chills or sweats. She further denies chest pain, sob, chest pain, urinary difficulties or blood in her stool. She has a history of IBS and is due for a colonoscopy in 3 months. She is a non-smoker, drinks 2 glasses of wine every two-three weeks and lives with her spouse of 17 years. BP 130/85, Weight 152, Temp 99.8. She is a well-nourished female in no apparent distress, appears comfortable. Neck : Supple. Thyroid: normal, no nodules. Heart: regular rate and rhythm, no edema. Lungs: Clear. Abdomen: soft and non-tender, with normal bowel sounds, no masses or hepatosplenomegaly, no guarding or rebound. Skin: clear, no rashes or ulcers or tattoos. UA: dip trace of glucose, trace of protein, all else neg.
1. Right lower quadrant pain, unknown etiology
2. Diarrhea
Plan: We will schedule her for an urgent abdominal US and CBC. Rule out bowel obstruction versus appendix. Spoke with GI MD from an outside GI Group and he feels Bowel obstruction is a possibility but suggests we await results of US before consult with General Surgeon. Patient instructed to go directly to ER if pain or symptoms worsen. Will call patient today with results.
Electronically signed: Jane Smith, MD