A 35 yo female presents here for first time with c/o sore throat and nausea. Denies significant medical history except seasonal allergic rhinitis and mononucleosis at age 17. Reports feeling nauseous about 10 days ago during menstruation, then developing into sore throat with swollen anterior cervical lymph glands over the past 7 days. Denies fever, chills, abdominal pain, vomiting, diarrhea, cough, sputum, SOB, CP, rash, H/A, or neck stiffness, but reports having fatigue and poor appetite. States that she took one dose of amoxicillin yesterday and has been taking advil about one dose a day for sore throat without good relief. LMP 2 weeks ago with normal blood loss. Had physical exam with blood w/u done about one year ago--all WNL except borderline high TSH. Reports having a monogamous relationship with her current partner more than one year.
ROUTINE MEDICAL EXAM - V70.0 (Primary)
Sore throat (viral) NOS - 462
Nausea - 787.03
ROUTINE MEDICAL EXAM
Lab:CH24/HDL,CBC/D/PLT AST (SGOT) 16 < 37 - u/l
LDL/HDL Ratio 1.26 0-3.55 -
PROTEIN 7.2 5.9-8.4 - gm/dl
ALBUMIN 4.3 3.2-5.2 - gm/dl
HCT 35.0 34.5-46.5 - %
HDL as % of Cholesterol 42 - %
Total Protein 7.2 5.9-8.4 - gm/dl
GLOBULIN 2.9 1.7-3.7 - gm/dL
LDL Cholesterol 77 < 100 -
POLYS 62.4 36.0-78.0 - %
WBC 5.81 3.40-11.80 - x10(3)/uL
CALCIUM 9.1 8.4-10.4 - mg/dl
Hematocrit 35.0 34.5-46.5 - %
CREATININE 0.7 0.6-1.3 - mg/dl
e-GFR 95 > 60 mL/min/1.73m2 -
BUN/Creat Ratio 18.6 10-28 -
HGB 11.9 11.5-15.6 - gm/dL
IRON 41 30-160 - mcg/dl
MCV 90.7 80.0-100.0 - fL
RBC 3.86 3.60-5.50 - x10(6)/uL
URIC ACID, SERUM 2.9 2.4-7.0 - mg/dl
CHOLESTEROL, TOTAL 146 < 200 - mg/dl
HDL CHOLESTEROL 61 >50 - mg/dl
BILIRUBIN, TOTAL 0.3 0.1-1.0 - mg/dl
Chol/HDL Ratio 2.39 -
Sore throat (viral) NOS
Lab:MONO SCREEN MONO SCREEN Negative Negative - N
Lab:CULTURE, THROAT, ROUTINE THROAT CULTURE NORMAL FLORA NORMAL FLORA - N
Appears viral origin--advise to drink plenty of fluids, gargle with warm salt water to ease a sore throat, get plenty of rest, and take acetaminophen or ibuprofen for pain and fever.
Counseling: Diet . Calcium supplementation .
99385 Preventive Care New Pt. Age 18-39.
36415 VENIPUNCT, ROUTINE*.
1.)THE PROVIDER CODED THIS A PREVENTIVE VISIT ONLY DOES THIS LABS WITH A LITTLE NOTES OF COUNSELING SUBSTANTIATE FOR PREVENTIVE VISIT?
NOTES:THIS VISIT HAS A VERY GOOD PHY.EXAM ON FILE AND I WILL ADD A SICK VISIT E/M FOR SORE THROAT AND NAUSEA.
NEEDS ANY OPINION,THANKS..