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ICD 10 CM codes 36-hour-old female infant is being evaluated for respiratory distress. Baby girl was born via c-section. CONSTITUTIONAL: Ht 50.1 cm, wt 3.2 kg, APGAR 7, Temp 98.7 RESPIRATORY: Tachypnea. Nostril flaring. Retracting. Wheezing and grunting with respiration. Pulse is 165 BPM. RR 76 BPM. SKIN: Skin is pale. Tongue and lips with bluish tinge. Nail beds are white. DIAGNOSTIC: CBC, blood levels, chest x-ray Dx: CXR confirms wet lung syndrome Code: __________ 2/13/XX Five-hour-old neonate is jaundice and delivering physician has determined that the child is Rh-positive, and mother is Rh-negative. The mother just moved to the area, and it cannot be determined from history whether the mother had screening for Rh incompatibility prior to delivery. EXAM: Abdomen: Liver and spleen are enlarged. Chest: Lungs are clear PLAN: Phototherapy and albumin infusion standard protocol as per written orders. IMPRESSION: Hemolytic disease of the newborn due to Rh isoimmunization Code: __________ This 7-day-old female neonate is brought in today by her parents for follow-up of pneumonia. Labs revealed presence of pseudomonas. CXR shows improvement. Baby seems to be responding well to the vancomycin. Continue current course and reevaluate in 3 days. Dx: Congenital pneumonia due to pseudomonas Codes: Note: All multiple fill-in-the-blanks are order specific. The patient is a male, born 36 hours ago and now experiencing convulsions. The product of a normal delivery with birth weight of 8 pounds 10 ounces. His vital signs are normal at this time. The nursing staff contacted the physician immediately upon noting the convulsions, which they said lasted several second. An EEG and ECG have been ordered, along with a complete blood workup. The baby will be monitored closely until all results are back. IMPRESSION: newborn convulsions Code: __________

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