HCS 216 Week 4 Reproductive System – Analyzing a Progress Note

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 HCS 216 Week 4 Reproductive System – Analyzing a Progress Note
 

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Reproductive System – Analyzing a Progress Note

Part 1

 

Using the following progress note, define the bolded terms within the chart provided. 

 

This patient is being assessed in the office by her OB-GYN.

 

Progress Note

 

Patient is a 25 y.o. female that presents for treatment of endometriosis. She has severe dysmenorrhea with an abnormal menstrual cycle for 3 years. There is a history of one pregnancy which was ectopic which did not require removal of the fallopian tubes. An ultrasound of the ovaries was performed 1 month prior to rule out ovarian cysts which was negative. Pregnancy test is negative.

 

Plan: repeat ultrasound, estradiol and progesterone levels. Will discuss possibility of uterine biopsy and surgical referral.

 

Impression: endometriosis

 

James Jones DO

 

*Do not forget to include the sources for your definitions.
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical term
 

 
 

 

Definition
 

 
 

 

Sources
 

 
 

 

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Part 2

 

Complete the following table using the information found in the Progress Note and the Internet. List the appropriate code(s) for the given medical terms and provide a justification explaining why you selected the given medical code(s).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical term
Medical code
Justification
Sources
Endometriosis, 

unspecified
 
 
 
Dysmenorrhea, 

unspecified
 
 
 
Ectopic pregnancy, other
 
 
 
 

 
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