Admission History Physical Question & Answer Guide (With Explanation)

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Original Question

Admission History and Physical Dr. Martinez admits a patient who will undergo a cesarean section. The diagnoses for this patient will include the gestation code to indicate twins, a code for the premature rupture of the membrane, a code for the malpresentation in multiple gestation, and a Z code to indicate multiple gestation placenta status. LOCATION: Inpatient, Hospital PATIENT: Joan Corcoran ATTENDING PHYSICIAN: Andy Martinez, MD CHIEF COMPLAINT: Spontaneous rupture of membranes HPI: This is a 24-year-old female with twin gestation, who now presents to labor and delivery with spontaneous rupture of membranes. The patient has had essentially an uneventful twin gestation and is currently at 34-3⁄7 weeks. Yesterday evening, she started having contractions. At 4 o’clock this morning, she had spontaneous rupture of membranes. Rupture produced clear fluids. There was no meconium or blood noted. After rupture, the patient’s contractions intensified and frequency increased. She presented to labor and delivery in active labor. Cervical exam revealed dilation of 3 cm (centimeter) with 100% effacement and breech presentation of the first twin. The patient was immediately notified of the risks, benefits, consequences, and alternatives to delivery by cesarean section. The patient is a consenting adult and elected to go forth with the procedure immediately. Dr. Sanchez was notified and will be performing the procedure. OB (OBSTETRICS) HISTORY: 1. 07/89 male, 8 pounds 2 ounces, 41 weeks, 17 hours labor, SVD (spontaneous vaginal delivery) 2. 07/94 male, 8 pounds 1 ounce, 40 weeks, 24 hours labor, SVD 3. 10/98 SAB (spontaneous abortion) at 10 weeks 4. 02/01 SAB at 11 weeks PAST MEDICAL HISTORY: 1. D&C (dilation and curettage) ALLERGIES: SULFA, develops a rash. FAMILY HISTORY:Father had an MI at age 65. He also had bladder cancer. Mother was noted to have ovarian cancer. No known birth defects in the family. She has three brothers and two sisters, all healthy. SOCIAL HISTORY:Unremarkable. Nonsmoker. Nondrinker. MEDICATIONS:Prenatal vitamins REVIEW OF SYSTEMS:As above PHYSICAL EXAM:Afebrile at 98° F. Vital signs are stable. BP is 120/80. General: Mild distress with contractions. Skin: Warm, dry, and pink. HEENT (head, ears, eyes, nose, throat): Unremarkable. No nystagmus. Acuity is normal. Peripheral vision normal. Lungs are clear. CVS: S1 (first heart sound) and S2 (second heart sound), regular rate and rhythm without murmur, rub, or gallop. Abdomen: Soft and nontender. Gravida. Palpable contractions. Cervix: 3 cm/100%/-1/breech. Extremities: No edema. No rash. No calf tenderness. Neurologic: Nonfocal. LABORATORY AND TESTS:A positive, antibody negative, rubella immune, hepatitis B surface antigen negative, HIV (human immunodeficiency virus) negative, Pap smear negative, hemoglobin 12.2, and group B negative. ASSESSMENT: 1. A 34-3⁄7 weeks’ twin gestation in active labor. 2. Breech presentation. 3. Prior history of spontaneous abortions. PLAN: The patient will be admitted to labor and delivery. Dr. Sanchez has been notified, and a cesarean section will be performed. The patient has been notified of the risks, benefits, consequences, and alternatives to the treatment. She is a consenting adult and elects to go forth with the procedure. She will have a permit signed and does wish to have a tubal ligation as well. This was also discussed in great depth. SERVICE CODE(S): ICD-10-CM DX CODE(S):

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