Case -T2-1B CLINIC PROGRESS NOTE

Case
-T2-1B CLINIC PROGRESS NOTE
This patient presents to the physician's office for an examination after a C-section the previous week.
LOCATION: Outpatient, Clinic
PATIENT: Beth Olgia
PHYSICIAN: Gary Sanchez, MD
SUBJECTIVE: Beth came in today for a postoperative exam. She underwent a C-section last week along with a tubal ligation. She was discharged on Monday of this week and is back in for a staple removal. Her blood pressure is still up, and today it is 170/102. Dr.
Naraquist has been following this. She says her blood sugars have been okay. Dr. Naraquist is following her blood sugars.
CURRENT MEDICATIONS:
1. Prenatal vitamins once a day.
2. Peri-Colace 1 b.i.d. (twice a day).
3. Darvocet p.r.n. (as needed).
4. Labetalol 600 mg (milligram) q.a.m. (every morning), 200 mg at 3 PM, and 600 mg at bedtime.
ALLERGIES: None
OBJECTIVE: Her wound is healing okay. The staples are removed. I told her not to do any heavy lifting over 20 pounds for the next 5 weeks, also no intercourse. She is to see us back again in 5 weeks.
T2-1B:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): _______________________________________________