- Description
HCS 216 Week 4 Reproductive System – Analyzing a Progress Note
Complete the University of Phoenix Material: 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 |