This Patient Is Seen in the Clinic at the Request

question 19

Short Answer

This patient is seen in the clinic at the request of Dr. Jones for evaluation of suprapubic pain. Patient is a 22-year-old black female G1 P0, LMP 12/20/xx, EDC 10/16/xx by 14-week ultrasound taken on 4/16/xx, 18 weeks with twin gestation. Presents with complaint of suprapubic sharp to mild pain with onset 2 months ago. Pain has become progressively worse. Patient has been seen by Dr. Jones for this pregnancy and has also been seen by Dr. Smith for this current complaint 2 weeks ago. Patient denies urgency and frequency of nocturia, denies hematuria, and denies discharge. Labs: CBC and urinalysis performed. Allergies: none. Past medical history: genital wart 1986. Past surgical history: wart removed by laser 1986. Social history: no smoking, illicit drugs, or alcohol.
PE: During an expanded problem-focused examination, the HEENT was found to be normal. FHT: A 148, B 146. Heart: normal. Lungs: CTA. Abdomen: gravid 20 cm. Slight tender suprapubic region. Vaginal exam: closed cervix, thick, long; no discharge. Extremities: negative for edema; UA loaded with bacteria and WBC.
Impression: 1. IUP at 18 weeks with twin gestation. 2. Acute UTI (the MDM was straightforward).
Recommendation: Keflex, 500 mg, and follow-up with Dr. Jones.
CPT Code: ____________________

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Definitions:

Brain Reorganization

The process by which the brain alters its structure and functioning in response to changes in its environment, typically following injury or through learning.

Endocrine System

The collection of glands that produce hormones to regulate processes such as growth, metabolism, and sexual function.

Genetics And The Environment

The study of how genetic makeup and environmental factors interact to influence an individual's development and traits.

Minnesota Twin Project

A research study that examines the psychological and behavioral differences between twins, particularly focusing on the effects of genetics vs. environment.