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Posted By angie on 01-16-2020, 16:36:26 in Ob-Gyn
not sure what dx code to use on this see below.

Chief Complaint
Patient New to practice
Pt unable to use a tampon.

History Of Present Illness
She is a 15 year old Caucasian/White female, G0 P0000, premenopausal patient. Her LMP was 12/31/2019.
The patient is referred by her pediatrician.
The patient comes in today for concerns regarding her anatomy as she is unable to place a tampon. She feels she is hitting something when she tries to place the tampon. She has watched videos on how to place a tampon. She has tried with small tampons. Her aunt is with her as her mother is deceased..
She complains of being unable to use a tampon. She is a dancer and would like to be able to use a tampon instead of pads.



Past Medical History
Disease Name Date Onset Notes
Gardasil given at other MD office/series -- --

Past Surgical History
Procedure Name Date Notes
*No Past Surgeries -- --




Medication List
Name Date Started Instructions
Child Chewable Vitamn Complete 18 mg iron oral tablet,chewable --
melatonin (bulk) 100 % miscellaneous powder use as directed

Allergy List
Allergen Name Date Reaction Notes
NO KNOWN DRUG ALLERGIES -- -- --

Family Medical History
Disease Name Relative/Age Notes
Cardiovascular Disease Grandfather (maternal)/75
Grandfather (paternal)/75
--
Migraine Father/
--
Diabetes Grandfather (maternal)/70
--
Thyroid Disease Aunt/30
Uncle/30
--
Depression Grandmother (paternal)/20
--
Cancer Breast Mother/
Deceased
*Cancer-Other Mother/
Bladder Deceased

Reproductive History
Menstrual
Last Menstrual Period: 12/31/2019 Method of Birth Control: None
Pregnancy Summary
Total Pregnancies: 0 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 Never --/-- -- --
Caffeine Never --/-- -- --
Denies All Domestic Violence -- --/-- -- --
Denies illicit substance abuse -- --/-- -- --
Heavy Amount of Exercise (4 or more times weekly) -- --/-- -- --
Single -- --/-- -- --
Tobacco Never --/-- -- --




Review of Systems
ConstitutionalDenies : fatigue, body aches, night sweats, weight loss
BreastsDenies : lumps, redness, nipple discharge, skin changes
CardiovascularDenies : chest pain, irregular heart beats, syncope
RespiratoryDenies : shortness of breath, wheezing, cough
GastrointestinalDenies : nausea, vomiting, diarrhea, constipation, blood in stools, hemorrhoids
GenitourinaryDenies : urgency, frequency, dysuria, incontinence affecting lifestyle
IntegumentDenies : rash, changes to existing skin lesions or moles
NeurologicDenies : tingling or numbness, headache
EndocrineDenies : polyuria, polydipsia, hirsutism
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

12/31/2019 10:58 AM 110/60 Sitting 145lbs 0oz 5' 9" 21.41 1.79


Physical Examination
ConstitutionalAppearance : well-nourished, well developed, alert and oriented, in no acute distress
ChestRespiratory Effort : breathing unlabored
CardiovascularHeart :
Auscultation : regular rate, normal rhythm, no murmurs present
GenitourinaryExternal Genitalia : normal appearance for age, no discharge present, no tenderness present, no inflammatory lesions present
Vagina : normal vaginal vault, no discharge present, no inflammatory lesions present, no masses present
Bladder : nontender to palpation
Urethra :
Urethral Meatus : no erythema or lesions present
Cervix : appearance healthy, no lesions present, nontender to palpation
Uterus : nontender to palpation, no masses present, contour: smooth to palpation, size normal, shape normal, mobility: normal
Adnexa : no adnexal tenderness present, no adnexal masses present
LymphaticLymph Nodes : no other lymphadenopathy present
SkinGeneral Inspection : no rashes present, no suspicious lesions present
General Palpation : no abnormalities on palpation
Neurologic/PsychiatricMental Status :
Orientation : grossly oriented to person, place and time
Mood and Affect : mood normal, affect appropriate






Assessment

Unable to use tampon-Instruction on tampon use, using a small tampon and angle of placement discussed.
If pt is still unable to use the tampon she can come in for assistance.



Problems Reconciled
Plan
MedicationsMedications have been Reconciled
Transition of Care or Provider Policy
InstructionsApproximately 25 minutes was spent with the patient today. All, or a majority of that time (> 50%), was spent counseling the patient.








Comments (1)
Posted By Melanie Witt on 01-27-2020, 15:34:27
Excellent question as nothing was found to be wrong. I would settle for a counseling code or worried well code. Z71.1, Person with feared health complaint in whom no diagnosis is made or Z71.89, Other specified counseling
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