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Posted By mary peabody on 05-31-2019, 13:59:00 in Ob-Gyn
Hello Melanie,

Given that the patient may have head trauma due to the MV and is on lovenox due to history of MVA and patient was referred from L & D triage to the trauma center, would these codes be more appropriate 09A.213, S09.90Xa, V49.50XA, Z86.718, Z79.01, Z3a.37? and not the Z04.1

Patient was in a car on her way out of her clinic appointment and the car was hit from the drivers side in a collision at moderate speed. Patient was restrained passenger in back seat. She reports that upon impact she felt a severe tightening over her abdomen where the seatbelt was located and hit the right side of her head against the door. She did not lose consciousness.
 
Remembers the incident completely. She does not endorse headache, vision changes, abdominal pain, VB, LOF. Feeling a significant amount of fetal movement. Not feeling uterine contractions.
 
Of note patient A positive.
 
She has been treated with lovenox during this pregnancy d/t provoked DVT in 2014 in the setting of OCP use. Patient does not report any bleeding episodes.
Physical Examination
General: Well appearing. No acute distress.
HEENT: Head examined thoroughly no signs of trauma, bony step-off, bleeding, or lesions noted.
CV: RRR
Lungs: Clear to auscultation, bilaterally.
Abdomen: Soft. Nontender. No signs of trauma noted.
GU: Gravid
Extremities: No peripheral edema

______ 37w2d who presents after MVA. Patient was re-triaged within 1 hour of presentation to SFGH for trauma evaluation and consideration of Head imaging given impact and patient's use of lovenox. Fetal status reassuring over our observation. Maternal status appeared reassuring but necessitated further monitoring and evaluation by trauma physicians

The patient is on blood thinners for hx of DVT on OCPs and now pregnant at term. Monitoring in triage of baby reassuring but did have some uterine irritability. Given head trauma and on blood thinners with viable term pregnancy, sent to trauma center, by ambulance. .
Comments (1)
Posted By Melanie Witt on 06-04-2019, 15:43:31
I would agree with the diagnoses you have chosen, but I probably would not use the head injury code since you are not evaluating that issue and referring her to trauma for that assessment.
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