Estward Hospital Chester Question & Answer Guide (With Explanation)

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Original Question

ESTWARD HOSPITAL 591 Chester Road Masters, FL 33955 DISCHARGE CLINICAL RESUME PATIENT: MORETTA, TERACIA DATE OF ADMISSION: 11/05/22 DATE OF DISCHARGE: 11/28/22 This is a 36-37-week-old female neonate delivered to a 25-year-old, gravida 2, para 1, who was a known breech presentation. Mother presented with complaint of vaginal bleeding, rupture of membranes, and abdominal pain and cramping. On exam found to be complete with large fecal impaction. Fetal heart rate 120 by monitor. To c-section room for disimpaction and cesarean section for breech. Delivered precipitously immediately after impaction was removed, breech presentation. OB moved baby to warmer. She was pale with no respiratory effort or heart rate. Ambu bagged with mask for 30 seconds. Intubation attempted. Code called. UAC was placed. ENT in place and bagged. No heart rate, no breath sounds, pale, cyanotic. Reintubated with chest rise, heart rate about 60. Chest compression stopped when heart rate above 120, color improved. Apgar 0 at 1 minute, 1 at 5 minutes, and 4 at 10 minutes. No spontaneous respiratory effort. Received sodium bicarbonate, epinephrine, and calcium. No grimace, no spontaneous movements. Pupils midpoint, nonreactive to light. NG placed for distended abdomen. Cord pH 7.33. Mother noted to have 50% abruptio placenta. Transferred to Neo. UAC was removed and replaced. UVC also placed. Physical exam on admission: weight 2,620 grams, pink, fontanelle soft, significant clonus of extremities, tone decreased. Pupils 2 cm and round, nonreactive to light. No movement, no grimace, no suck, good chest rise. Equal breath sounds, no murmur. Pulses 2+. Perfusion good. Abdomen soft and full. No masses. Normal female genitalia externally. Anus patent. Extremities no edema. Skin—Mongolian spot sacrum and both arms, single café-au-lait spot left flank 1.5 cm × 0.5 cm. Palate intact. IMPRESSION: 36-37 week AGA female Status postcardiopulmonary arrest Rule out sepsis At risk for hypoxic ischemic encephalopathy PHYSICAL EXAM ON DISCHARGE: 23 days of age, weight 2,520 grams, head circumference 35, pink. Anterior fontanelle soft. Heart—II/VI murmur radiating to the axilla. Chest clear. Abdomen soft, positive bowel sounds, gastrostomy tube intact, wound is okay. Neuro—irritable. The infant has an anal fissure at 12 o’clock that has caused some blood streaks in the stool. FINAL DIAGNOSES: 36-37 week appropriate for gestational age female History post cardiac arrest Respiratory arrest Rule out sepsis Hypoxic ischemic encephalopathy, mild Gastroesophageal reflux and feeding problems Nancy Odom, MD Be sure to list the codes, one code per box, in the correct order, from top to bottom. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices. The number of spaces provided does not indicate the number of codes required to accurately report this encounter. What is/are the correct diagnosis code(s)?

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