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Posted By angie on 12-11-2018, 15:19:57 in Ob-Gyn
IS THIS VISIT BILLABLE OUT SIDE OF OB PACKAGE?

Chief Complaint
Hypertension follow-up after Delivery


History Of Present Illness
This is a 24 year old Caucasian/White female, presents for a post partum problem visit. She underwent Induction for preeclampsia, MgSo4, and NSVD 12/7/2018 ago. Procedure was done by Dr. XXXXXX. She was sent home on Nifedepine 60XLmg BID. Pt was discharged yesterday. Her labs had normalized prior to discharge and her edema has resolved. Since being home her BP were 157/94, 145/98/136/92. She woke up feeling funny during the night and her BP was 118/75. This afternoon she had BP of 165/100 and 162/104 when the baby was screaming. She has had a mild HA off and on.

She reports some zig zags in her vision for a short time earlier today. She denies fever, nausea, vomiting, and.
This problem is due to complication/condition during pregnancy.

Past Medical History
Disease Name Date Onset Notes
* Date of Last Chlamydia screen (CDC recommended) 05/04/18 Negative
* Date of Last PAP 6/2017 NORMAL PER PT

Past Surgical History
Procedure Name Date Notes
wisdom teeth removal 1/2013 --

Medication List
Name Date Started Instructions
nifedipine 60 mg oral tablet extended release 12/09/2018 --

Allergy List
Allergen Name Date Reaction Notes
NO KNOWN DRUG ALLERGIES -- -- 11/21/2018 -

Family Medical History
Disease Name Relative/Age Notes
Cardiovascular Disease Grandfather (paternal)/40
--
Brain Neoplasm, Malignant Grandfather (paternal)/52
Grandmother (paternal)/57
Stroke Grandfather (maternal)/
Thyroid Disease, unspec Grandmother (maternal)/40
Mother/40
Uncle/40
Cancer of Ovary Grandmother (maternal)/77
High Cholesterol / Hyperlipidemia Brother/
Father/
Diabetes Aunt/
Brother/
Father/
Grandmother (maternal)/
Uncle/
--
Depression Aunt/
Cancer Breast Aunt/
*Other FAMILY HISTORY OF FRATERNAL TWINS, pt has fraternal twin; grandfather's uncles and grandmother's cousins are fraternal twins

Reproductive History
Menstrual
Age Menarche: 11 Cycle Interval(Days): 28 Menses Duration(Days): 7
Flow: Medium Number of Tampons: 3 Number of Pads: 1
Last Menstrual Period: 03/03/2018 Certainty of LMP Date: YES Method of Birth Control: None
Clots?: No Breakthrough Bleeding?: No HRT?: No
Pregnancy Summary
Total Pregnancies: 1 Full Term: 0 Premature: 0
Ab Induced: 0 Ab Spontaneous: 0 Ectopics: 0
Multiples: 0 Living: 0

social History
Finding Status Start/Stop Quantity Notes
Alcohol Former --/-- -- --
Caffeine Current every day --/-- 1 C/DAY --
Denies All Domestic Violence -- --/-- -- --
Denies illicit substance abuse Never --/-- -- --
Married -- --/-- -- --
Minimal Amount of Exercise (Once weekly or less) -- --/-- -- --
Spouse Partner Name -- --/-- -- EVAN
Tobacco Never --/-- -- 11/21/2018 -

Immunizations
NameDate Admin Mfg Trade Name Lot Number Route Inj VIS Given VIS Publication
Influenza10/16/2018 PMC Fluzone, quadrivalent, preservative free UJ045AC IM RD 10/16/2018
Comments:
Tdap Adult10/16/2018 PMC ADACEL U6069BA IM LD 10/16/2018
Comments:

Review of Systems
ConstitutionalDenies : fatigue, body aches, night sweats, weight loss
EyesDenies : impaired vision
HENTDenies : headaches, sinus congestion
CardiovascularDenies : chest pain, syncope
RespiratoryDenies : shortness of breath, wheezing, cough
GastrointestinalDenies : nausea, vomiting, diarrhea, constipation, blood in stools, hemorrhoids
GenitourinaryDenies : urgency, frequency, dysuria, incontinence affecting lifestyle
NeurologicDenies : tingling or numbness, headache
EndocrineDenies : polyuria, polydipsia, cold intolerance, heat intolerance
PsychiatricDenies : anxiety, depression
Heme-LymphDenies : easy bleeding, lymph node enlargement or tenderness

Vitals
Date Time BP Position Site LR Cuff Size HR RR TEMP (F) WT HT BMI kg/m2 BSA m2 O2 Sat HC

12/10/2018 03:24 PM 150/96 Sitting 148lbs 13oz 5' 3" 26.36 1.73

Physical Examination
ConstitutionalAppearance : well-nourished, well developed, alert and oriented, in no acute distress
ChestRespiratory Effort : breathing unlabored
Auscultation : normal breath sounds
CardiovascularHeart :
Auscultation : regular rate, normal rhythm, no murmurs present
GastrointestinalAbdominal Examination : abdomen nontender to palpation, tone normal without rigidity or guarding, no masses present
Hernias : no obvious hernias present
GenitourinaryExternal Genitalia : Deferred
Vagina : Deferred
SkinGeneral Inspection : no rashes present, no suspicious lesions present
Neurologic/PsychiatricMental Status :
Orientation : grossly oriented to person, place and time
Mood and Affect : mood normal, affect appropriate

No edema in her legs or feet.

Assessment
Hypertension in pregnancy, pre-eclampsia, severe, delivered/postpartum 642.52/O14.15
Pt to stay on her current dosage as she has only been on this dosage since yesterday and she did have a low BP at which she was symptomatic.
Comments (1)
Posted By Melanie Witt on 12-12-2018, 13:09:10
Absolutely billable. This visit is not part of routine postpartum care. As you will be using an OB ICD10 code for this visit, you might consider adding a modifier -24 to the E/M service as this is unrelated to the delivery recovery.
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