5. Reisa Haven, a 39-year-old female, was sent by Dr. Alfaya to Dr. Avery, an OB-GYN, for an office consultation. She had
been suffering with moderate pelvic pain, a heavy sensation in her lower pelvis, and marked discomfort during sexual
intercourse. In a detailed history, Dr. Avery noted the location, severity, and duration of her pelvic pain and related
symptoms. In the review of systems, Reisa had positive findings related to her gastrointestinal, genitourinary, and endocrine
body systems. Dr. Avery noted that her past medical history was noncontributory to the present problem. The detailed
physical examination centered on her gastrointestinal and genitourinary systems with a complete pelvic exam. Dr. Avery
ordered lab tests and a pelvic ultrasound in order to consider uterine fibroids, endometritis, or other internal gynecologic
pathology. MDM complexity was moderate.
E/M code: