[Answered]: 4/15/XX Maria Gomez S: A 35-year-old female…

4/15/XX Maria Gomez S: A 35-year-old female established patient is seen for a new complaint of left lower quadrant pain; 1 wk. duration. Symptoms: mild fever, decreased appetite, and mild constipation for 1 wk. Pt denies abdominal injury, change in urination, or abnormal menstruation. LMP: 3/12/XX. O: Temp: 100.2deg F; BP 130/80, HR 80; RR 18. Lungs: Clear. Abdomen: Both sides mildly hyperactive, flat, mild guarding LLQ, rebound neg; fullness LLQ; no discrete masses; no HSM. Rectal: Normal tone; no masses; guaiac positive. Pelvic: Cervix closed, uterus and ovaries normal, fullness lt lat adnexa c tenderness. Lab: CBC, elevated. WBC c mild lt shift; UA, normal; HCG, pregnancy test negative. A: Probable diverticulitis of sigmoid colon based on clinical picture. P: Obtain barium enema to R/O diverticulitis. Begin antibiotics and dietary restriction during acute phase and follow up in three days. e/m cpt code