Yes Ivonne, it is indeed it is the physician's job to give the MDM. Since you brought it to the thread for evaluation , I come out with my opinion . See if it could help -
The key sentences:
1.no fetal heart beat (should have been through US).
2.Physician documented threatened abortion. (No bleeding; no mention about Os opened or not)
3.Lab tests and cytopath ordered-which infers the patient is not in immediate danger but lab tests needed for later evaluation of sequlae of threated abortion /or missed abortion going for threated abortion and for treatment modalities
(All these documentation made after Comprehensive History and Comp examination.)
4.Time is requested or bought by the Physician to plan a definitive plan of D&C /Suction curettage at a later date.
MDM for this would go for moderate.
It cannot be taken down to a lower level 'LOW' because danger cannot be ruled out.
It cannot be upgraded to high because it is not critical at this stage and it could continue to be at the optimal level of risk or late turn out to be critical, if she starts bleeding or the lab test like coagulation profile are not favorable. I am sure physician would have given a counseling to return any time if she starts bleeding.
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