blaymon
Networker
What would you code this office visit?
Patient:23-year-old female (new patient)
Chief Complaint: Concerns about sexually transmitted infections (STIs) after her ex-boyfriend tested positive for Chlamydia.
History of Present Illness:
Ms. Smith presents to the office today concerned about her potential exposure to sexually transmitted infections after her ex-boyfriend informed her that he tested positive for Chlamydia. She reports that she has not had any symptoms but wants to be tested for Chlamydia and other STIs, including gonorrhea, hepatitis B and C, HIV, syphilis, bacterial vaginitis, and candidal vaginitis.
Past Medical History:
No significant past medical history
Medications:
None
Vital Signs:
Temp: 98.6°F
BP: 120/80 mmHg
HR: 72 beats/min
RR: 16 breaths/min
Ht: 5’ 3”
Wt: 155 lbs.
Physical Examination:
General: well-appearing
HEENT: atraumatic, PERRLA
Neck: no adenopathy
Lungs: CTAB
Heart: RRR without murmur
Skin: no rash
Patient performed a self vaginal swab. We drew blood for other STIs listed in the plan.
Assessment:
Exposure to Chlamydia
STI screening
Plan:
Order testing for NuSwab (1 swab- Chlamydia, gonorrhea, trichomonas, bacterial vaginitis, and candida vaginitis) hepatitis B antibody and antigen and hepatitis C antibody, HIV- western blot, and syphilis- RPR.
Prescribe Doxycycline 100mg BID for 10 days.
Advise Ms. Smith to inform any recent sexual partners about her potential exposure and to encourage them to get tested as well
Patient:23-year-old female (new patient)
Chief Complaint: Concerns about sexually transmitted infections (STIs) after her ex-boyfriend tested positive for Chlamydia.
History of Present Illness:
Ms. Smith presents to the office today concerned about her potential exposure to sexually transmitted infections after her ex-boyfriend informed her that he tested positive for Chlamydia. She reports that she has not had any symptoms but wants to be tested for Chlamydia and other STIs, including gonorrhea, hepatitis B and C, HIV, syphilis, bacterial vaginitis, and candidal vaginitis.
Past Medical History:
No significant past medical history
Medications:
None
Vital Signs:
Temp: 98.6°F
BP: 120/80 mmHg
HR: 72 beats/min
RR: 16 breaths/min
Ht: 5’ 3”
Wt: 155 lbs.
Physical Examination:
General: well-appearing
HEENT: atraumatic, PERRLA
Neck: no adenopathy
Lungs: CTAB
Heart: RRR without murmur
Skin: no rash
Patient performed a self vaginal swab. We drew blood for other STIs listed in the plan.
Assessment:
Exposure to Chlamydia
STI screening
Plan:
Order testing for NuSwab (1 swab- Chlamydia, gonorrhea, trichomonas, bacterial vaginitis, and candida vaginitis) hepatitis B antibody and antigen and hepatitis C antibody, HIV- western blot, and syphilis- RPR.
Prescribe Doxycycline 100mg BID for 10 days.
Advise Ms. Smith to inform any recent sexual partners about her potential exposure and to encourage them to get tested as well