Luann is a 42-year-old woman who was diagnosed with endometriosis approximately five years ago. She was treated conservatively since the diagnosis, but has had continuing pelvic and lower back pain, hematuria, dyspareunia, abdominal pain and cramping. She told her physician at the time of her last annual exam that she was "done with all this" and that she was tired of the pain. While Luann is
still perimenopausal, she is done with childbearing and she has elected to undergo a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Besides the endometriosis, Luann has a PMH of hypertension, GERD, and hyperthyroidism. She successfully underwent the TAH/BSO and was discharged the fourth post-operative day with instructions on wound care. She will be seen in the office in four weeks or sooner if she develops any complications.
Dx: Endometriosis of uterus and ovaries; HTN, GERD, hyperthyroidism
First-listed/principal diagnosis: ________
Secondary diagnoses: ________
Fill in the blank with correct word.
First-listed/principal diagnosis: ________
Answer: Endometriosis of uterus – N80.0
Secondary diagnoses: ________
Answer: Endometriosis of ovaries – N80.01, HTN – I10; GERD – K21.9; hyperthyroidism – E05.90
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