History of Present Illness: Pt presents with vaginal bleeding in pregnancy. Pt states she had

History of Present Illness: Pt presents with vaginal bleeding in pregnancy. Pt states she had brownish discharge for 3-4 days. This morning she began having severe cramping pain with dark red blood and clots. Pt states she was seen by OB and her urine preg was negative 3 times, however serum bHCG was positive. No history of SAB. Medical History: Noncontributory Surgical History: Bowel resection, therapeutic abortion Vaginal Bleeding Pregnant Gravida: 3 Para: 1 (H/o elective AB/D&C) Last menstrual period: 3/26/XX Pregnancy confirmed: Yes Pregnancy confirmed by: Serum hCG Estimated gestational age: 6 weeks Onset of bleeding: Sudden Duration of bleeding: 2 days Timing: Continuous Description of bleeding: Dark red and clots Context of bleeding: at rest Progression: Improving Worsened by: Nothing Relieved by: Nothing Associated symptoms: abdominal pain Associated symptoms: no back pain, no fever, no nausea, no vomiting, no dizziness, no weakness, no fatigue, no dysuria, no urgency, no dyspareunia, no vaginal discharge, no syncope and not near syncope Location of abdominal pain: LLQ and RLQ Quality of abdominal pain: Cramping Timing of abdominal pain: Intermittent Prenatal care this pregnancy?: Yes Prenatal complications?: No Prior ED/OB clinic visits for this problem No Risk factors for vag bleeding during pregnancy: no hx of ectopic pregnancy and no prior miscarriage Review of Systems Constitutional: Negative for fever, chills, diaphoresis, appetite change and fatigue. Eyes: Negative for visual disturbance. Respiratory: Negative for cough, shortness of breath and wheezing. Cardiovascular: Negative for chest pain, palpitations and leg swelling. Gastrointestinal: Positive for abdominal pain. Negative for nausea, vomiting, diarrhea, constipation, blood in stool and abdominal distention. Genitourinary: Positive for vaginal bleeding and pelvic pain. Negative for dysuria, urgency, hematuria, vaginal discharge, difficulty urinating, vaginal pain and dyspareunia. Musculoskeletal: Negative for myalgias, back pain and arthralgias Skin: Negative for color change, pallor, rash and wound. Neurological: Negative for dizziness, syncope, weakness, light-headedness, numbness and headaches. Psychiatric/Behavioral: The patient is not nervous/anxious. Vitals: Temperature: 98.6°F Pulse: 62 Respirations: 18 Blood Pressure: 110/70 SpO2: 98% on room air Height: 5’5ft Weight: 195 BMI: 32.4 Physical Examination: Constitutional: She is oriented to person, place, and time. She appears well-developed and well-nourished. Non-toxic appearance. She does not have a sickly appearance. She does not appear ill. No distress. HENT Head: Normocephalic and atraumatic. Nose: Nose normal. Eyes: Conjunctivae and EOM are normal. Pupils are equal, round, and reactive to light. Neck: Trachea normal. Neck supple. No thyromegaly present. Cardiovascular: Normal rate, regular rhythm, normal heart sounds and intact distal pulses. No murmur heard. Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. She has no decreased breath sounds. She has no wheezes. She has no rales. She exhibits no tenderness. Abdominal: Soft. Normal appearance and bowel sounds are normal. She exhibits no distension. There is no tenderness. There is no rebound and no guarding. Genitourinary: There is no rash, tenderness or lesion on the right labia. There is no rash, tenderness or lesion on the left labia. Cervix exhibits no motion tenderness and no friability. There is bleeding in the vagina. No tenderness in the vagina. No signs of injury around the vagina No vaginal discharge found. Moderate amount bleeding from cervix. Cervix closed. +clots. No tissue seen. Neurological: She is alert and oriented to person, place, and time. GCS eye subscore is 4. GCS verbal subscore is 5. GCS motor subscore is 6. Skin: Skin is warm and dry. No rash noted. She is not diaphoretic. No erythema No pallor. Psychiatric: She has a normal mood and affect. Her behavior is normal. Judgment and thought content normal. MDM:Number of Diagnoses or Management Options Spontaneous abortion: new and requires workup Vaginal bleeding: new and requires workup Amount and/or Complexity of Data Reviewed Clinical lab tests: ordered and reviewed Radiology exams: ordered Risk of Complications, Morbidity, and/or Mortality Presenting problems: moderate Diagnostic procedures: low Management options: low Final Diagnosis: Spontaneous abortion What is the correct ICD 10 code

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