Chief Complaint & History of Present Illness :
18 year old female presents with pregnancy issues at 9 weeks.Patient reports having stomach pain last night that felt like kicking, but she knew it was too early.She states that her stomach felt heavy, and she woke up with the same pain this morning along with vaginal spotting.Standing and walking aggravates her pain.Patient is G2P1.
Past Medical History :
PMH: None
Primary MD: MCC
Historical Diagnoses (Full Problem List)
AP – Abdominal pain (2016), Ovarian cyst rupture (2016)
Allergies
Bupropion(hives)
Home Medications
Analpram-HC Cream, 1 application rectally 4 times per day PRN hemorrhoids
Colace, 250 milligram orally every day
Epsom Salt Solution, 1 application topically 3 times per day
Motrin, 600 milligram orally every 6 hours PRN pain
prenatal ukn type,
Tucks 50 % Medicated Pads, 1 pad topically every day PRN skin irritation
Immunizations
Tdap – 115 (2017)
Social History
Unremarkable
Tobacco Use
None Reported : TOBACCO HISTORY Last Documented By: AMANDA TARGETT, RN on 01/20/19:31
Alcohol Use
None Reported : ALCOHOL HISTORY Last Documented By: KRISTEN HOFFMAN, RN on 12/01/18:53
Recreational Drug Use
None Reported : RECREATIONAL DRUG HISTORY Last Documented By: IAN R. CANTOR, RN on 04/07/21:04
Review Of Systems
ROS: No fever or chills
No visual changes
No sore throat or earache
No chest pain or palpitations
No shortness of breath or cough
No pain with urination or hematuria
No abdominal pain nausea vomiting or diarrhea
No skin rashes
No focal weakness or numbness
No bruising or ecchymosis
ROS: Rest of the review of systems is negative except as listed in the HPI
Vital Signs
Most Recent Set of Vitals:
BP: 110/64 09/30/2019 11:29
Pulse: 94 09/30/2019 11:29
Temp: 36.7 C 09/30/2019 11:29
Resp: 16 09/30/2019 11:29
02 Sat: 99%(Room Air) 09/30/2019 11:29
Calculated BMI: 27.5 09/30/2019 11:29
Physical Exam
General: Alert and oriented x3.Well developed, well nourished, well appearing.Anxious resting comfortably in bed.
Non icteric.
Hematologic: no bruising or ecchymosis.
Skin: Warm and dry, no rashes or lesions.
HENT: Normocephalic, atraumatic, pharynx moist and non injected.
Eyes: PERRL, EOMI, conjunctiva pink with no discharge.
Neck: Supple, no adenopathy.
Respiratory: Lungs clear, no rales, no rhonchi, no wheezing, no accessory muscle use.
Heart: Regular rate and rhythm, no murmurs.
Abdomen: Soft, nontender, active bowel sounds, nondistended, no guarding or rebound.
GU: no CVA tenderness.
Extremities: No edema, no calf tenderness.
Neuro: No focal weakness, no facial asymmetry, moves all extremities normally, normal speech pattern, normal gait.
Date / Time : Ultrasound of : PREG 1ST TRI SINGLE ENDOVAG
Ultrasound was : Interpreted by Radiologist
FINDINGS: Uterus: Again noted is a partial uterine duplication. Endometrium: Within the left horn there is an intrauterine gestation with fetal pole and yolk sac identified.Fetal heart rate is 205 BPM.Sub membranous collections compatible with sub chorionic hematoma are seen with 2 collections identified measuring 12 x 13 x 3 mm and 23 x 17 x 8 mm. Cervix is closed. Ovaries: Right ovary is normal in size and appearance.Again noted is a left ovarian or paraovarian cyst currently measuring 22 x 14 x 12 mm Free Fluid: None. Crown-rump length corresponds to a sonographic age of 9 weeks and an EDD of 05/04/2020.LMP is 07/28/2019 corresponding to a clinical age of 9 weeks 1 day and EDD of 05/03/.
IMPRESSION:
1.Nine week living intrauterine gestation within left uterine horn of a partially duplicated uterus.
2.Two subchorionic hematomas are noted.
Medical Decision Making (MDM) :
Medical decision making this is an 18-year-old female who is pregnant she had some minor pink spotting as well as lower abdominal discomfort. Ultrasound shows a 9 week intrauterine pregnancy with good heart beat. Patient is clinically well she is Rh positive no signs of infection. Plan patient is reassured. Plan of recheck at Community Clinic for prenatal care as scheduled. Vaginal rest. Recheck if increased pain or bleeding. Impression threatened AB.
ED Diagnosis (Current Problem List) :
Assessment and Planning:
Dx: Threatened miscarriage
Disposition
Disposition Decision Date/Time:
D/C from ED to: Home
CPT code :
99284-25
Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function.
76801 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester, transabdominal approach; single or first gestation
76817 Ultrasound, pregnant uterus, real time with image documentation, transvaginal
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