caso 7 samantha

Bayamon Community College 17 Calle Maceo Bayamon, PR, 00961 Tel. Patient Name: samantha padilla nieves Record:07-NPN Date: 12/6/2023 DOB: 5/21/1994 Age: 29.55 BCC XVIII ENCOUNTER REPORT SUBJECTIVE Chief Complaint samantha padilla nieves is a 29 years old female. The reason for her visit is pregnancy Follow up visit. Patient refers complaints of: back pain. The patient indicates that from 1 to 10 her pain is: Hurts little more 4 and refers that her pain/complaint occurred since 2 week(s). Gynecological History Menstrual History - LMP : 05/06/2022 Age al Menarche : 12 Frecuency: : monthly Interval between Periods : 28 days Sexually History - Ever had sex : active Number of Partners (Lifetime) : 1 Current Method of Contraception : pregnant Past Contraceptive History : rhythm Obstetric History Grava : 2 PARA : No Comments : had a miscarriage Clinical Pelvimetry 13.5cm Genetic Screening/Teratology Counseling History of: : trisomy 21 Do you have? Do you have? - Urine leaks when you cough or sneeze : yes Decrease in energy level : no Past Medical History STATUS TITLE CODE ONSET ABATEMENT RESOLVED Superficial endometriosis of the uterus N80.01 12/6/2023 Social History Social History • Folic Acid intake: : yes • Regular Exercise: : walk 20 minutes daily

Bayamon Community College 17 Calle Maceo Bayamon, PR, 00961 Tel. Patient Name: samantha padilla nieves Record:07-NPN Date: 12/6/2023 DOB: 5/21/1994 Age: 29.55 BCC XVIII Smoking History and Habits Smoking status - Smoking Status : Never smoker Drinking -Patient does not drinks alcoholic beverange Other Habits -Patient does not use illegal drugs Family History RELATIONSHIP CONDITION DECEASED GENDER Father Malignant neoplasm of colon, unspecified Male Allergies STATUS CAUSED BY CRITICALITY REACTION SEVERITY IDENTIFIED CATEGORY ACTIVE No Known Allergy Medications STATUS TITLE FORMULATION DURATION DISPENSE SIG START END REFILL ACTIVE folic acid folic acid 800 mcg tablet 0 0 Tablet 12/6/2023 12/6/2023 0 Hospitalization No known history of hospitalizations Review of Systems Genito Urinary : urine leaks at night OBJECTIVE Laboratory Results Chief Complaint (2023-12-06) OBSERVATION VALUE Reason for visit pregnancy Follow up visit Chief Complaint back pain Pain Scale Hurts little more 4 Duration of symptoms 2 week(s) Severity Mild Menstrual History (2023-12-06) OBSERVATION VALUE

Bayamon Community College 17 Calle Maceo Bayamon, PR, 00961 Tel. Patient Name: samantha padilla nieves Record:07-NPN Date: 12/6/2023 DOB: 5/21/1994 Age: 29.55 BCC XVIII Patient does not drinks alcoholic beverange true Patient drinks alcoholic beverages false Other Habits (2023-12-06) OBSERVATION VALUE Patient does not use illegal drugs true Hospitalization (2023-12-06) OBSERVATION VALUE No known history of hospitalizations true Review of Systems (2023-12-06) OBSERVATION VALUE Genito Urinary urine leaks at night Vital Signs (2023-12-06) OBSERVATION VALUE Blood Pressure - Sitting 122/85 Weight 155 lbs Height 5' 7'' / 170 [in_i] BMI 24.27 kg/m2 BMI percentile 0 kg/m2 BMI Diagnostic Body mass index (BMI) 20-29, adult BMI Category Normal weight BSA 1.7 m2 Heart Rate (Pulse) 98 /min Resp. rate 17 /min Temperature 37.2 Cel Pain Scale Hurts little more 4 Oxygen saturation 97 % Inhaled oxygen 0 % Pregnancy Status Pregnant Blood Group AB+ Notes Notes Constitutional (Phy Exam) (2023-12-06) OBSERVATION VALUE Well developed, well nourished, well gropmed, no deformities, normal habitues true Respiratory (2023-12-06) OBSERVATION VALUE

Bayamon Community College 17 Calle Maceo Bayamon, PR, 00961 Tel. Patient Name: samantha padilla nieves Record:07-NPN Date: 12/6/2023 DOB: 5/21/1994 Age: 29.55 BCC XVIII Normal true Cardiovascular (2023-12-06) OBSERVATION VALUE Denies symptoms, no chest pain, shortness of breath or palpitations. false Gastrointestinal (2023-12-06) OBSERVATION VALUE No symptoms referred false Lymphatic (2023-12-06) OBSERVATION VALUE Normal true Skin (2023-12-06) OBSERVATION VALUE Normal true Neurologic/Psychiatric (2023-12-06) OBSERVATION VALUE Normal true Breast (2023-12-06) OBSERVATION VALUE Normal true External Genitalia (2023-12-06) OBSERVATION VALUE Normal true Urethral Meatus (2023-12-06) OBSERVATION VALUE Urethral appeared normal, with correct size, no lesions or discharge. false Small false Large false Hypospadias false Polyp false Lesions false Urethra (2023-12-06)

Bayamon Community College 17 Calle Maceo Bayamon, PR, 00961 Tel. Patient Name: samantha padilla nieves Record:07-NPN Date: 12/6/2023 DOB: 5/21/1994 Age: 29.55 BCC XVIII OBSERVATION VALUE Clear & Symmetric Breath Sounds, Chest non Tender, No use of accessory muscle. false Vagina (2023-12-06) OBSERVATION VALUE Normal false Cervical (2023-12-06) OBSERVATION VALUE Normal, Motion Tenderness. false Adnexal (2023-12-06) OBSERVATION VALUE Normal, Mass, Tenderness. false Uterus (2023-12-06) OBSERVATION VALUE Normal, Enlarged, Tender. false Rectal (2023-12-06) OBSERVATION VALUE No tenderness false Week 20-28 (2023-12-06) OBSERVATION VALUE Weeks Gestation 24 U/A negative GC/Chamidia negative Dental Care (2023-12-06) OBSERVATION VALUE Referral/RX false Weight Control (2023-12-06) OBSERVATION VALUE Referral/RX false Proper diet, calcium intake (2023-12-06) OBSERVATION VALUE Referral/RX false

Bayamon Community College 17 Calle Maceo Bayamon, PR, 00961 Tel. Patient Name: samantha padilla nieves Record:07-NPN Date: 12/6/2023 DOB: 5/21/1994 Age: 29.55 BCC XVIII Family violence (2023-12-06) OBSERVATION VALUE Referral/RX false Hyperlipidemia (2023-12-06) OBSERVATION VALUE Referral/RX false Obesity/diabetes mellitus (2023-12-06) OBSERVATION VALUE Referral/RX false Safety belts (2023-12-06) OBSERVATION VALUE Referral/RX false Breast self exam (2023-12-06) OBSERVATION VALUE Referral/RX false Drugs (tabacco,alchol,others) (2023-12-06) OBSERVATION VALUE Referral/RX false Vital Signs Vital Signs (2023-12-06) OBSERVATION VALUE Blood Pressure - Sitting 122/85 Weight 155 lbs Height 5' 7'' / 170 [in_i] BMI 24.27 kg/m2 BMI percentile 0 kg/m2 BMI Diagnostic Body mass index (BMI) 20-29, adult BMI Category Normal weight BSA 1.7 m2 Heart Rate (Pulse) 98 /min Resp. rate 17 /min Temperature 37.2 Cel Pain Scale Hurts little more 4 Oxygen saturation 97 % Inhaled oxygen 0 %

Bayamon Community College 17 Calle Maceo Bayamon, PR, 00961 Tel. Patient Name: samantha padilla nieves Record:07-NPN Date: 12/6/2023 DOB: 5/21/1994 Age: 29.55 BCC XVIII Obstetrician Evaluation Week 20-28 - Weeks Gestation : 24 U/A : negative GC/Chamidia : negative ASSESSMENT Diagnostic Evaluation se evalua al paciente a sus 24 semanas de embarazo. al momento todo transcurre con normalidad Diagnostic STATUS DIAGNOSTIC SEVERITY TYPE CODE ONSET ACTIVE Encounter for supervision of normal first pregnancy, second trimester None Not Specified Z34.02 12/6/2023 ORDERS Imaging Orders STATUS CODE STUDY PATIENT INSTRUCTIONS DIAGNOSTICS ACTIVE 76811 US PREG UTERUS W/DETAIL FETAL ANAT 1ST GESTATION Z34.02 RECOMMENDATIONS Recommendation se le recomienda descanso y no realizar fuerzas ni doblarse mucho para evitar el dolor en la espalda baja. se orienta a la paciente sobre las almohadas de maternidad ya que, en muchas ocasiones ayuda a mejorar la postura y evitar dolores musculares. EVALUATION AND MANAGEMENT Evaluation and Management DESCRIPTION CODE QUANTITY DIAGNOSTICS MODIFIERS OTHER OFFICE/OUTPATIENT ESTABLISHED LOW MDM 20-29 MIN 99213 1 Z34.02 N/A