CASE 5
HPI: 20-year-old female, estimated gestational age 25.3 weeks,(Patient is pregnant.) who presents with red staining after wiping with toilet paper (Patient's complaint.) this afternoon. No abdominal pain. Contractions: Negative. Fetal Movement: Present.
ROS:
Constitutional: Negative.
Headache: Negative.
Urinary: Negative.
Nausea: Negative.
Vomiting: Negative.
Past Medical/Family/Social History:
Medical History: Negative.
Surgical History: Negative.
Social History: Alcohol: Denies. Tobacco: Denies. Drugs: Denies.
EXAM:
General Appearance: No acute distress.
Abdominal: Soft. Non-tender.
Vagina: Blood clots size: 1.5 cm and amount 2. Discharge:Pink.
No hyphae, BV, or TRICH, and CX not irritated.
Cervix: Deferred.
Uterus: Fundal height: 24 cm.
MDM: Labs: FFN, UA R+M, C+S, GC/chlamydia, CBC, type and RH, DAU.
Labs reviewed and WNL.
Ultrasound: Negative for placenta previa.
NOTES: Patient continues with contractions mildly, but does not feel it. Patient given Celestone I/M. D/C and to return tomorrow for repeat Celestone injection.
Diagnosis: Threatened premature labor (Report the definitive diagnosis.) What diagnosis code(s) are reported?
a) O60.00 (Preterm labor without preterm delivery, unspecified trimester)
b) O09.803 (Threatened preterm labor, third trimester)
c) O34.419 (Maternal care for other abnormalities of cervix, unspecified trimester)
d) O80 (Encounter for full-term uncomplicated delivery)