Soap Notes 3

Running head ICD -10 CODES SOAP NOTES 1 ICD -10 Codes Soap Notes Name Institution Affiliation ICD-10 CODES SOAP NOTES 2 On abdominal pain 25 years old female G3p2002 with RLQ1 pain in the abdomen lasted for five months, has reported two periods in this year it has regular lasting for 26 to 30 days each. LMP was three months ago, no cervical or ovarian history in the family. Soft abdomen no abdomen guarding in the four quadrants the bowel sounds regular, pelvic gives cervical motion tenderness and on the left motion tenderness also. Mild left tenderness of the ovary no uterine enlargement. Negative urine pregnancy test. The history of the patient given and even the clinical findings of the left ovarian are suspected, the transvaginal ultrasound is ordered for the ovarian cyst. A one week follow up is scheduled. N94.89 other specific disorders of a female N92.5 menstruation that is not regular R10.31 pain in another part of the lower quadrant R10.813 tenderness of left lower quadrant Z87.42 individual disease history Looking on the lamp of the breast a perimenopausal female, 35 years old.G4p4004.LMP August 20, 2018. Had a normal last pap.she has no history of STD, her family had no history of cervical or ovarian cancer. Breast cancer in the family is positive -the two sisters and the mother. Sisters are Paranormal per civic exam, right breast normal examined except for 1.7 cm mass on right lower/outer quadrants. Left breast normal. The patient gives pap results with regul