Discharge Diagnoses Preterm Explained for Students (Easy Guide)

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Discharge Diagnoses: Preterm infant. 34 6/7 weeks of gestation, single liveborn by cesarean Feeding problems, newborn Hypothermia, newborn Jaundice of prematurity Pneumothorax Respiratory distress of newborn History of Present Illness: BG Camille Walker was born to a 27 y/o, G2 P1, blood type B+, Antibody Screen negative, HBsAg negative, Serology Non-reactive, Rubella immune, HIV unknown, GBS negative, GC negative, Chlamydia negative mother. There was spontaneous labor. Membranes were ruptured SROM on 6/10. The duration of the rupture was 0 Days 9 Hours 2 Minutes. Fluid was clear. Mother received Betamethasone – 1 dose during labor. Also, she received one dose of Ampicillin and one dose of Erythromycin. Primary – elective cesarean section delivery at ABC Hospital on 6/11. Presentation was breech. The attending obstetrician was Preeti Singh, MD. The delivery was attended by Sharon Holmes, MD for the following indications: Single, liveborn by cesarean, Preterm infant, 34 6/7 weeks of gestation and by cesarean section. Apgar scores were: 9 at 1 minute, 9 at 5 minutes. Birthweight was 2575 grams. In the delivery room the baby was stimulated. Suctioned with a bulb. Patient admitted to on 6/11 for the following indication(s): -respiratory distress. Admission/Stabilization Comments: Good color and cry in DR, but mild grunting/retractions on arrival in NICU. Placed on NCPAP. Vitals: Temperature: 98.6°F Pulse: 150 Respirations: 33 Weight: 2575g Physical Examination: GENERAL: Level of distress is mild. Nourishment type is well nourished. Overall appearance is premature. NCPAP in Place HEAD/FACE: Normocephalic. Sutures opposed. Anterior fontanel flat. EYES: Red reflect present bilaterally. EARS: Normally set. Internal ear exam not performed. NOSE/MOUTH/THROAT: No nasal flaring; nares patent bilaterally. No cleft. Gag reflex present. NECK/THYROID: Supple. LYMPHATIC: No adenopathy noted. RESPIRATORY: No retractions noted. Breath sounds clear and equal with good air exchange. CARDIONASCULAR: S1, S2 normal. No murmur appreciated. Regular rate and rhythm. Pulses equal. ABDOMEN: Bowel sounds present. Soft, non-tender without masses. No hepatosplenomegaly. GU/RECTAL: Female genitalia consistent with gestational age. Anus patent. SKIN/HAIR: No lesions noted. BACK/SPINE: No abnormalities noted. No sacral dimple. MUSCULOSKELETAL/EXTREMITIES: No deformities noted. Hips stable. Moves all extremities symmetrically. NEUROLOGICAL: Reflexes 2+ and symmetric. Muscle tone appropriate for gestational age. Hospital Course:Hypothermia, newborn Born at 34 3/7 weeks after premature ROM. Mother received 1 dose B-methasone several hrs PTD. Mother began making cervical change and infant breech, therefore delivered by elective c-section. Requires intensive monitoring and observation for need for continued thermoregulation. Temperature stable in an isolette. At risk for feeding problems requiring gavage supplementation. At risk for jaundice with anticipated peak 5-7 days of age. Isolette for temperature regulation. Monitor for A/B. Bilirubin with morning labs. Follow clinically. Respiratory Distress of Newborn Good color and cry in DR with sats in 90s, but mild grunting/retractions on arrival in NICU. O2 sats in NICU in high 70s to low 80s in RA. Placed on NCPAP (5) at 30% O2 weaned quickly to 25 – 28%. Initial ABG = 7.16/60/63/22/-7 soon after admission. CXR showed mild haziness diffusely with increased interstitial markings suggesting mild RDS. Unknown GBS and PTL, therefore assessed to r/o sepsis. Follow-up CBG showed improvement on NCPAP, but still with mild resp acidosis. Resp distress increased on DOL #1, CXR = left PTX. Needle thoracostomy for 40 ml air @ 12:40. Jaundice of Prematurity T/D bili at 6.70/0.5 at 27 hrs. T bili=12.6 at 73hrs. T blili=14.3 at 82hrs. Phototherapy started. Repeat bilirubin in morning. Feeding Problems, Newborn Initially NPO due to respiratory distress. Started on D10W at 80 ml/kg/day, TPN was then started, on 6/12 -baby was stable on CPAP feed were initialed al 5ml q 3hrs, she received one feeding and then was made NPO due to increasing respiratory distress and need for intubation. UVC was place, Total fluids with TPN at 80ml/kg/day, D10W with heparin y into TPN. Tolerating NG feeds overnight at 5 ml q3, but with worsening resp status, made NPO this am. No stooling since birth, quite likely this is largely due to morphine use. AXR this am does not reveal dilated loops of bowel or signs of obstruction but there is a paucity of air in the rectum. Not weighed due to lability of baby. Voiding well. BMP normal except for elevated BUN – does not appear to be dehydrated/hypovolemic. Monitor labs. Monitor input/output. Follow weight. Communication: Spoke with parents. We discussed persistent PTX and peds pulmonology request for more detailed imaging and evaluation. Parents expressed understanding and asked appropriate questions. what are the correct CPT code Do not put diagnosis codes

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