tintin
Contributor
Hello,
please see chart notes below & help to confirm if the Dx of Herpes needed.
Can I added B00.89 - Other herpesviral infection??
Provider code: Vulvar lesion LESION OF VULVA N90.89
CC: new patient, vulvar lesion, abnormal bleeding
HPI: new patient visit and vulvar lesion. She is overall doing well. Recently out of 3 yr relationship and now with new casual partner. For last week has had intense itching and burning on the vulva. Was treated for a UTI thru urgent care but does not have dysuria. No improvement since completing antibitoics
*Also compaining of new ocp causing irregular bleeding--she is accustomed to having 2 day menses but now on the low dose ocp her bleeding is much heavier--starting on third week of pills but not missing any pills.
Physical Exam:
GU: BUS wnl; there are small multiform open lesions on the posterior forchette and also near the urethra. vagina w/o erythema or atrophy, lesions or discharge; Cervix w/o CMT or lesions; uterus not enlarged, no masses or tenderness; adenexa w/o tenderness or masses.
A/P: vulvar lesions, and abnormal bleeding on low dose ocp
Lesion: herpes swab but will empirically treat her lesions---they are consistent with herpes. Rest of her STD screening is up to date
*
Other orders
- norgestimate - ethinyl estradiol (ORTHO-CYCLEN, SPRINTEC) 0.25-35 mg-mcg Tablet per tablet; Take 1 tablet by mouth once a day.
**
Pt was seen today for skin lesion(s). *
Diagnoses and all orders for this visit:*
Encounter for initial prescription of contraceptive pills
- THINPREP IMAGING SYSTEM PAP & HPV MRNA E6/E7,C.TRACHOMATIS/N.GONORRHOE; Future
*Vulvar lesion
- CULTURE, HERPES SIMPLEX VIRUS (HSV), NON-BLOOD; Future
*
Other orders
- norgestimate - ethinyl estradiol (ORTHO-CYCLEN, SPRINTEC) 0.25-35 mg-mcg Tablet per tablet; Take 1 tablet by mouth once a day.
- valACYclovir (VALTREX) 1000 mg Tablet; Take 1 tablet by mouth 2 times a day for 10 days.
Helen H.
*
please see chart notes below & help to confirm if the Dx of Herpes needed.
Can I added B00.89 - Other herpesviral infection??
Provider code: Vulvar lesion LESION OF VULVA N90.89
CC: new patient, vulvar lesion, abnormal bleeding
HPI: new patient visit and vulvar lesion. She is overall doing well. Recently out of 3 yr relationship and now with new casual partner. For last week has had intense itching and burning on the vulva. Was treated for a UTI thru urgent care but does not have dysuria. No improvement since completing antibitoics
*Also compaining of new ocp causing irregular bleeding--she is accustomed to having 2 day menses but now on the low dose ocp her bleeding is much heavier--starting on third week of pills but not missing any pills.
Physical Exam:
GU: BUS wnl; there are small multiform open lesions on the posterior forchette and also near the urethra. vagina w/o erythema or atrophy, lesions or discharge; Cervix w/o CMT or lesions; uterus not enlarged, no masses or tenderness; adenexa w/o tenderness or masses.
A/P: vulvar lesions, and abnormal bleeding on low dose ocp
Lesion: herpes swab but will empirically treat her lesions---they are consistent with herpes. Rest of her STD screening is up to date
*
Other orders
- norgestimate - ethinyl estradiol (ORTHO-CYCLEN, SPRINTEC) 0.25-35 mg-mcg Tablet per tablet; Take 1 tablet by mouth once a day.
**
Pt was seen today for skin lesion(s). *
Diagnoses and all orders for this visit:*
Encounter for initial prescription of contraceptive pills
- THINPREP IMAGING SYSTEM PAP & HPV MRNA E6/E7,C.TRACHOMATIS/N.GONORRHOE; Future
*Vulvar lesion
- CULTURE, HERPES SIMPLEX VIRUS (HSV), NON-BLOOD; Future
*
Other orders
- norgestimate - ethinyl estradiol (ORTHO-CYCLEN, SPRINTEC) 0.25-35 mg-mcg Tablet per tablet; Take 1 tablet by mouth once a day.
- valACYclovir (VALTREX) 1000 mg Tablet; Take 1 tablet by mouth 2 times a day for 10 days.
Helen H.
*
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