Case 1XYZ Internal Medicine Physicians200 Main StAnywhere, USAPatient Name: Susan Lopez; DOB: 2/10/1968; Sex: FVisit Date: 3/1/24Last Office Visit: 11/3/23Chief Complaint: Rectal Bleeding/vaccine requestMs. Lopez is a 64-year-old female with a family history significant for colon cancer who now presentswith rectal bleeding x 2 weeks. Patient is known to me from previous referral for screening colonoscopygiven her family history; previous exam 6 months ago was negative for polyps or obvious pre-cancerouslesions. Patient states she noticed bright red blood with stools 3-4 times over last few weeks. Deniesconstipation, fever, loss, and night sweats. Denies easy bleeding, bruising, epistaxis, and family history ofbleeding disorders. Appetite is good. Susan also is requesting the Tdap vaccine as she is to become anew grandparent in 1 month.PE: T 99.0, weight 162 poundsActive middle-aged female in no acute distress. HEENT: no scleral icterus; nares clear. Mucousmembranes moist; dentition normal. Heart: Regular rate and rhythm; no murmurs. Lungs: clear toauscultation bilaterally. Abdomen: soft, non-tender, non-distended. No organomegaly. No masses.Skin: no bruising, no jaundice. GU: normal sphincter tone. No stool in vault. No massesLabs: occult blood positive in clinic today; ordered CBC and liver panel to rule out other inflammatoryprocess.Assessment: Middle-aged female with new onset of hematochezia; occult blood positive with familyhistory of colon cancer. Rule out mass vs. diverticulitis. Doubt inflammatory process.Plan: Arranged for expedited diagnostic colonoscopy next week. Explained procedure and risks in detailwith patient. Ordered standard bowel prep with instructions to patient. Tdap vaccine administeredIM in right deltoid.Assign the code(s) and any applicable modifier(s) for this visit ______