dbolivar1
Networker
Hello,
I'm needing help on the dx code for the following:
Would I use O07.39 along with symptoms?
Reason for Visit OB
Abdominal pain
History of Present Illness
xx-year-old female presenting for abdominal pain. She was initially seen in the emergency department and sent to OB triage. She had a medication abortion about 5 weeks ago by Planned Parenthood at approximately 11-week gestational age. She reports they did an ultrasound prior to the abortion. She initially felt very well but has had vaginal discharge since. Over the past week the discharge has started to become more malodorous and is described as creamy/yellow. She has also had diarrhea/loose stools for about 1 week. She reports that this morning around 0300 she was awoken by sharp left-sided lower abdominal pain which has been ongoing. She states she feels generally unwell and weak. She also vomited twice this morning and has continued to feel nauseated. She has been sexually active twice since her abortion and is not using contraception. She has not had she has not had any fever, shortness of breath, chest pain, urinary symptoms.
In the ED the patient received oxycodone and ondansetron which did not improve her symptoms. She had basic lab work sent and arrived with an IV in place. A transvaginal ultrasound was performed which was preliminarily reported as concerning for retained material and possible arteriovenous malformation.
Review of Systems
A 10-point ROS including general, eyes, ears nose and throat, cardiovascular, respiratory, gastrointestinal, genitourinary, skin, neurologic, musculoskeletal, psychiatric, endocrine, hematologic, lymphatic, allergic/immunologic was completed by the patient and was positive per HPI. The remainder of the 10 system review was otherwise negative.
Physical Exam
Vitals & Measurements
Vital Signs Recent (Ranges for last 30 hrs)
Temperature: 36.5 (36.5 - 36.5)
Heart Rate: 86 (86 - 86)
SBP Cuff: 112 (112 - 112)
DBP Cuff: 78 (78 - 78)
Resp Rate: 16 (16 - 16)
Weight: 52.8 kg as of 06/06/23
Height: No Data Available
General: Alert and oriented, uncomfortable appearing.
Eye: Normal conjunctiva.
HENT: Normocephalic, no obvious lesions
Neck: Supple
Lungs: Non-labored respiration
Heart: Normal rate and rhythm
Abdomen: Soft, significant middle and left lower abdominal discomfort without rebound or peritoneal signs
Musculoskeletal: Moving all extremities, no obvious injuries.
Skin: Skin is warm, dry and pale
Neurologic: Awake, alert, and oriented, no obvious focal deficits.
Genitourinary: No hematuria
Psychiatric: Cooperative, appropriate mood and affect.
Speculum exam: normal appearing cervix, thick white/yellowish discharge, no blood, swabs sent
Diagnostics
TRANSABDOMINAL AND TRANSVAGINAL PELVIC ULTRASOUND
CLINICAL HISTORY: Other (specify)/ovarian torsion
Per chart review: Patient had a miscarriage 5 weeks ago. No beta hCG was
obtained at the time of imaging interpretation.
COMPARISON: None.
TECHNIQUE: Real time transabdominal ultrasound was performed to survey the
entire pelvis. Endovaginal ultrasound was performed to provide high resolution
imaging of the endometrium and ovaries.
FINDINGS:
Uterus measures 8.6 x 8.9 x 4.6 cm.
Endometrial thickness measures 15 mm with heterogenous material. Serpiginous
hypoechoic structures within the endometrial cavity and myometrium demonstrating
flow on Doppler imaging with high velocity flow and low resistive indices.
Normal right ovary measures 2.9 x 2.0 x 2.4 cm (volume of 7.3 mL).
Normal left ovary measures 3.4 x 1.9 x 3.0 cm (volume of 10.3 mL). Left adnexal
corpus luteum.
Doppler flow demonstrated to both ovaries.
Small volume free pelvic fluid.
IMPRESSION:
Retained products of conception. Some features could be seen with arteriovenous
malformation, which should be considered in the setting of bleeding and if
elective abortion was surgical.
Assessment/Plan
26 y/o female G3P2 presenting about 5 weeks after an elective medication abortion at 11 weeks with abdominal pain, malaise, vaginal discharge, leukocytosis
#Abdominal pain
#Vaginal discharge
#Diarrhea
#Vomiting
-Patient is s/p medication abortion the first week of May reportedly at 12 weeks gestation
-Signs and symptoms concerning for retained products
-Ultrasound with possible retained products with concern for AVM
-WBC 14
-Pain and nausea control
-Zosyn given
-Plan for D+C
Thank you!
I'm needing help on the dx code for the following:
Would I use O07.39 along with symptoms?
Reason for Visit OB
Abdominal pain
History of Present Illness
xx-year-old female presenting for abdominal pain. She was initially seen in the emergency department and sent to OB triage. She had a medication abortion about 5 weeks ago by Planned Parenthood at approximately 11-week gestational age. She reports they did an ultrasound prior to the abortion. She initially felt very well but has had vaginal discharge since. Over the past week the discharge has started to become more malodorous and is described as creamy/yellow. She has also had diarrhea/loose stools for about 1 week. She reports that this morning around 0300 she was awoken by sharp left-sided lower abdominal pain which has been ongoing. She states she feels generally unwell and weak. She also vomited twice this morning and has continued to feel nauseated. She has been sexually active twice since her abortion and is not using contraception. She has not had she has not had any fever, shortness of breath, chest pain, urinary symptoms.
In the ED the patient received oxycodone and ondansetron which did not improve her symptoms. She had basic lab work sent and arrived with an IV in place. A transvaginal ultrasound was performed which was preliminarily reported as concerning for retained material and possible arteriovenous malformation.
Review of Systems
A 10-point ROS including general, eyes, ears nose and throat, cardiovascular, respiratory, gastrointestinal, genitourinary, skin, neurologic, musculoskeletal, psychiatric, endocrine, hematologic, lymphatic, allergic/immunologic was completed by the patient and was positive per HPI. The remainder of the 10 system review was otherwise negative.
Physical Exam
Vitals & Measurements
Vital Signs Recent (Ranges for last 30 hrs)
Temperature: 36.5 (36.5 - 36.5)
Heart Rate: 86 (86 - 86)
SBP Cuff: 112 (112 - 112)
DBP Cuff: 78 (78 - 78)
Resp Rate: 16 (16 - 16)
Weight: 52.8 kg as of 06/06/23
Height: No Data Available
General: Alert and oriented, uncomfortable appearing.
Eye: Normal conjunctiva.
HENT: Normocephalic, no obvious lesions
Neck: Supple
Lungs: Non-labored respiration
Heart: Normal rate and rhythm
Abdomen: Soft, significant middle and left lower abdominal discomfort without rebound or peritoneal signs
Musculoskeletal: Moving all extremities, no obvious injuries.
Skin: Skin is warm, dry and pale
Neurologic: Awake, alert, and oriented, no obvious focal deficits.
Genitourinary: No hematuria
Psychiatric: Cooperative, appropriate mood and affect.
Speculum exam: normal appearing cervix, thick white/yellowish discharge, no blood, swabs sent
Diagnostics
TRANSABDOMINAL AND TRANSVAGINAL PELVIC ULTRASOUND
CLINICAL HISTORY: Other (specify)/ovarian torsion
Per chart review: Patient had a miscarriage 5 weeks ago. No beta hCG was
obtained at the time of imaging interpretation.
COMPARISON: None.
TECHNIQUE: Real time transabdominal ultrasound was performed to survey the
entire pelvis. Endovaginal ultrasound was performed to provide high resolution
imaging of the endometrium and ovaries.
FINDINGS:
Uterus measures 8.6 x 8.9 x 4.6 cm.
Endometrial thickness measures 15 mm with heterogenous material. Serpiginous
hypoechoic structures within the endometrial cavity and myometrium demonstrating
flow on Doppler imaging with high velocity flow and low resistive indices.
Normal right ovary measures 2.9 x 2.0 x 2.4 cm (volume of 7.3 mL).
Normal left ovary measures 3.4 x 1.9 x 3.0 cm (volume of 10.3 mL). Left adnexal
corpus luteum.
Doppler flow demonstrated to both ovaries.
Small volume free pelvic fluid.
IMPRESSION:
Retained products of conception. Some features could be seen with arteriovenous
malformation, which should be considered in the setting of bleeding and if
elective abortion was surgical.
Assessment/Plan
26 y/o female G3P2 presenting about 5 weeks after an elective medication abortion at 11 weeks with abdominal pain, malaise, vaginal discharge, leukocytosis
#Abdominal pain
#Vaginal discharge
#Diarrhea
#Vomiting
-Patient is s/p medication abortion the first week of May reportedly at 12 weeks gestation
-Signs and symptoms concerning for retained products
-Ultrasound with possible retained products with concern for AVM
-WBC 14
-Pain and nausea control
-Zosyn given
-Plan for D+C
Thank you!