dbolivar1
Networker
Hello,
I'm needing help what dx to use. Would it be Z09 or O03.9?
Chief Complaint:
follow up miscarriage
History of Present Illness:
30-year-old female who comes in today to follow-up after miscarriage and vaginal bleeding with following beta-hCG. [1] This was a desired pregnancy. This is her second miscarriage. She had some symptoms of abnormal vaginal discharge and had a negative vaginal swab test for any infection at last visit. She has not been having nausea or vomiting or other signs of pregnancy over the last week. She has had no abdominal pain. She has no continued bleeding. She did have bleeding with clots in the early part of this process. She was told that she had a large sac in previous visits and at last visit there was a very small half centimeter sac. Her beta-hCG started out at 10,000 and in September and was 800 last week and now is down to 275.
Bedside Imaging - empty uterus:
IMAGING:
The patient had a transvaginal ultrasound identifying an empty endometrial cavity .
Her uterus was empty.
There was no free fluid.
Her adnexae were normal
Assessment/Plan:
30-year-old G2, P2 here for follow-up after vaginal bleeding and a drop in her beta-hCG that most likely represents a miscarriage that is nearly complete. Her uterus is empty and her beta-hCG has gone down to 275. She will repeat her beta-hCG next Tuesday and we will follow these weekly until they go to 0 because there was never a yolk sac or intrauterine pregnancy seen however there was a large sac that did appear to be a real gestational sac and most likely a blighted ovum. Patient expressed understanding. I did review her last several notes. [3] . [2] we will also screen her for STD today at her request.
Ordered:
HCG-lab
HCG-lab
HCG-lab
Std Amp
Thank you in advance!
I'm needing help what dx to use. Would it be Z09 or O03.9?
Chief Complaint:
follow up miscarriage
History of Present Illness:
30-year-old female who comes in today to follow-up after miscarriage and vaginal bleeding with following beta-hCG. [1] This was a desired pregnancy. This is her second miscarriage. She had some symptoms of abnormal vaginal discharge and had a negative vaginal swab test for any infection at last visit. She has not been having nausea or vomiting or other signs of pregnancy over the last week. She has had no abdominal pain. She has no continued bleeding. She did have bleeding with clots in the early part of this process. She was told that she had a large sac in previous visits and at last visit there was a very small half centimeter sac. Her beta-hCG started out at 10,000 and in September and was 800 last week and now is down to 275.
Bedside Imaging - empty uterus:
IMAGING:
The patient had a transvaginal ultrasound identifying an empty endometrial cavity .
Her uterus was empty.
There was no free fluid.
Her adnexae were normal
Assessment/Plan:
30-year-old G2, P2 here for follow-up after vaginal bleeding and a drop in her beta-hCG that most likely represents a miscarriage that is nearly complete. Her uterus is empty and her beta-hCG has gone down to 275. She will repeat her beta-hCG next Tuesday and we will follow these weekly until they go to 0 because there was never a yolk sac or intrauterine pregnancy seen however there was a large sac that did appear to be a real gestational sac and most likely a blighted ovum. Patient expressed understanding. I did review her last several notes. [3] . [2] we will also screen her for STD today at her request.
Ordered:
HCG-lab
HCG-lab
HCG-lab
Std Amp
Thank you in advance!
