Query - Acute Tubular Necrosis (ATN)

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Acute Tubular Necrosis (ATN) Query form

Documentation in the medical record indicates that this patient has been admitted with or diagnosed as having ACUTE KIDNEY INJURY. The following is also documented in the medical record:

• ·       Creatinine levels [list all and dates]
• ·       FENa =
• ·       Urine sodium concentration =
• ·       Urine output of _________ over ___ hours
• ·       IV contrast
• ·       Medication [if potentially neurotoxic]:
• ·       Other:

Based on your medical judgment, can you further clarify in the progress notes confirmed or suspected underlying cause for this patient’s condition such as:

• ·       Acute Tubular Necrosis
• ·       Acute Cortical Necrosis
• ·       Acute Glomerulonephritis
• ·       Pre-Renal Acute Kidney Injury
• ·       Other condition: (please specify)
• ·       None of the above /Not applicable

In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular diagnosis is desired or expected.

Thank you!

Forceps Transbronchial Biopsy

 

This is to inform everyone that there has been a change of advice from AHA Coding Clinic on the correct coding of transbronchial biopsies performed with the use of forceps.

 

The original response from AHA Coding Clinic stated that documentation of the use of forceps to perform transbronchial biopsies was not sufficient to determine the root operation performed (Excision or Extraction). A provider query should be submitted to determine the correct root operation for ICD-10-PCS code assignment.

 

AHA Coding Clinic recently submitted the question to the Editorial Advisory Board (EAB) and has now updated their response. EAB has reviewed and stated “Forceps are a type of cutting tool. Typically, forceps are used to remove an intact piece of tissue and the use of forceps is coded to the root operation Excision, whereas a needle aspiration is a collection of individual cells and is coded to the root operation Extraction.”

 

When transbronchial biopsies are performed with the use of forceps should be coded to the root operation Excision per EAB advice. Please note, this applies to forceps transbronchial biopsies only. Transbronchial needle aspiration biopsies and transbronchial Cryobiopsies should still be coded to the root operation Extraction.

QUERY - Acute Kidney Injury

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Acute Kidney Injury Query Form

Documentation in the medical record indicates that this patient has been admitted with or diagnosed as having .

 

The following lab is also documented in the medical record: [include criteria that apply]

· Creatinine on admission =

· Baseline Creatinine (if known):

· Correction of serum creatinine from ____ to _____ following rehydration

· Urine output :

 

Based on your medical judgment, can you please clarify in the progress notes the diagnosis associated with these findings such as:

· Acute Kidney Injury

· Acute on Chronic Renal Failure

· Chronic Kidney Disease (Stage, if known)

· Other (please specify)

· None of the above / Not applicable

 

In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular diagnosis is desired or expected.

 

Thank you!

CMS POA Indicators

 CMS POA Indicator Options and Definitions

Code	Reason for Code
Y	Diagnosis was present at time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as "Y" for the POA Indicator.
N	Diagnosis was not present at time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as "N" for the POA Indicator.
U	Documentation insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as "U" for the POA Indicator.
W	Clinically undetermined.  Provider unable to clinically determine whether the condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as "W" for the POA Indicator.
1	Unreported/Not used.  Exempt from POA reporting.  This code is equivalent to a blank on the UB-04, however; it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as "1" for the POA Indicator. The “1” POA Indicator should not be applied to any codes on the HAC list.  For a complete list of codes on the POA exempt list, see  the Official Coding Guidelines for ICD-10-CM.

Inpatient Hip Replacement chart - DS

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DISCHARGE SUMMARY

 

Admission Diagnosis: Pre-Op Diagnosis Codes:

   * OSTEOARTHRITIS OF RIGHT HIP

 

Discharge Diagnosis: Post-Op Diagnosis Codes:

   * OSTEOARTHRITIS OF RIGHT HIP

 

Procedures Performed: Procedure(s) (LRB):

HIP REPLACEMENT ANTERIOR APPROACH TOTAL (Right)

 

Reason for Hospitalization: Surgical treatment of right hip disease

 

Hospital Course: XXX was admitted for the above procedure. She followed our standard clinical pathway for total joint surgery. There were no unusual events.

 

Discharge Disposition: She was discharged to Home with Home Health after meeting the criteria for discharge.

 

Complications: none

 

Condition at Discharge: stable

 

Medications and instructions: See Discharge Instructions/AVS

 

Follow up appointments: 

Inpatient Hip Replacement chart - H&P

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H&P

 

Procedure Information:

Pre-Op Diagnosis Codes:

   * OSTEOARTHRITIS OF RIGHT HIP

Procedure(s) with comments:

HIP REPLACEMENT ANTERIOR APPROACH TOTAL - HANA table

Big C-arm #2 on opposite side of table

Total hip 1, anterior hip set, Depuy add ons

Gripper x 1, Drain bag

Depuy Pinnacle cup, Actis stem, Corail for back-up

Requested Anesthetic type:  Spinal

 

I contacted patient and confirmed that I was speaking to the correct person.

 

Patient expressed understanding and agreed to proceed with the video visit and treatment if necessary. Consent documented in visit navigator. Connection was successful.

 

Chief Complaint and History of Present Illness:

XXX is a 72 Y female with a history of R hip OA for which she is scheduled for surgery.

 

Patient Active Problem List

  OSTEOARTHRITIS OF RIGHT HIP

          Added automatically from request for surgery

          1225017

 

  HYPERLIPIDEMIA

 

  ANOSMIA

 

  SENILE PURPURA

 

  ESOPHAGEAL SPASM

 

  HX OF ABNL PAP SMEAR

 HX of CIS diagnosed and treated in 1984

 

  HX OF COLONOSCOPY

          Mod to severe diverticula, repeat screening 6-2023

 

  DIVERTICULOSIS OF COLON

 

  HX OF SKIN CANCER

 

  LUMBOSACRAL RADICULOPATHY

 

  ACTINIC KERATOSIS

 

  HTN (HYPERTENSION)

 

  ASTHMA

 

 

Resolved Hospital Problems

No resolved problems to display.

 

Past Surgical History:

Procedure           Laterality             Date

•             CONE BIOPSY OF CERVIX                                

                for CIS 1984

 

Allergies

Allergen               Reactions

•             Co-Trimoxazole  

                                rash

•             Codeine                

                                swelling

•             Hydrocodone-Acetaminophen    

                                upset stomach.; tylenol is ok

•             Nsaids, Non-Selective [Non-Steroidal Anti-Inflammatory Agents] Renal Toxicity

                                Cr increased to 1.78 after several days of PO Toradol.

•             Prochlorperazine              

                                hospitalization

 

Tobacco Use

•             Smoking status: Never Smoker

•             Smokeless tobacco:        Never Used

Vaping Use

•             Vaping Use:        Never used

Substance Use Topics

•             Alcohol use:       No

                                Alcohol/week:  0.0 standard drinks

•             Drug use:             No

 

 

E-Cigarettes/Vaping

                Questions           Responses

                E-Cigarette/Vaping Use Never User

 

 

Social History

 

Substance and Sexual Activity

Drug Use             No 

 

Family History: non-contributory

 

Family History of Anesthesia Complications: Unknown

 

Personal History of Anesthesia Complications: none

 

Review of Systems:

General: Denies fever, chills, weight change, fatigue and weakness

Cardiovascular: Denies chest pain, orthopnea and palpitations with exercise or at rest

Respiratory: Denies recent SOB and cough (productive)

Neuro: Denies fainting, seizures and headaches Falls: no, Delirium: no, Assistive devices: uses a cane sometimes

GI: Denies GERD

GU: Denies dysuria, frequency and urgency

Heme: Denies bleeding but has easy bruising

Musculoskeletal: Denies joint pain and decreased ROM neck

Skin: Denies rashes and skin changes over the surgical site

Other: none

Has the patient had a positive COVID test in the last 7 weeks? no

Has the patient had a COVID test ordered ? yes

 

Physical Exam:

General appearance: alert, well appearing, and in no distress

Neck: normal range of motion

Respiratory: no respiratory distress

Mental status: alert, oriented to person, place, and time, normal mood, behavior, speech, dress, motor activity, and thought processes

 

Most recent information from chart review:

Estimated body mass index is 25.06 kg/m² as calculated from the following:

  Height as of 3/31/22: 1.626 m (5' 4").

  Weight as of 3/31/22: 66.2 kg (146 lb).

SpO2 Readings from Last 3 Encounters:

03/31/22              98%

10/11/18              98%

02/27/18              95%

 

BP Readings from Last 3 Encounters:

03/31/22              138/72

07/06/21              135/75

06/17/21              140/76

 

Pulse Readings from Last 3 Encounters:

03/31/22              106

07/06/21              95

06/17/21              98

 

Temp Readings from Last 3 Encounters:

03/31/22              99 °F (37.2 °C) (Temporal)

07/06/21              98.3 °F (36.8 °C) (Temporal)

01/28/20              99.5 °F (37.5 °C) (Tympanic)

 

 

Pre-Operative Screening

 

Pregnancy Testing:

N/A (male, nonmenstruating female, hx of hysterectomy)

 

Obstructive Sleep Apnea Criteria:

None

 

Exercise/Functional Capacity:

4-6 mets: e.g. Yard work, climb a flight of stairs, walk up a hill and Patient's current level of activity includes the following: Up until recently was able to walk to the gym and exercise a bit 2-3 times per week.  Limited by hip pain, no SOB

 

History of Cardiac Stent: No           

 

Objections To Blood Transfusions: NO

 

Review of Other Relevant Data:

EKG: date 2018, result

Baseline artifact is present

Sinus tachycardia

RSR' in V1 or V2, probably normal variant

Right axis deviation

Nonspecific ST-T wave changes.

Compared with previous tracing no significant

change.

 

Echo: none

No results found for this or any previous visit (from the past 4320 hour(s)).

 

Cardiac Stress Test: none

 

Patient Class: Hospital Ambulatory Surgery

 

Pneumonia Prevention Education: N/A, hospital ambulatory surgery

 

Life Care Planning:

Medical Decision Maker? Patient provided information today--Tim Molinare (listed as emergency contact)

Advanced Directive? no

 

Assessment and Plan:

XXX is a 72 Y female is optimized for planned surgery.

Preliminary ASA Class: 2

The following studies have been ordered or are pending at the time of this visit: EKG to be done in pre-op

 

Patient Active Hospital Problem List:

 OSTEOARTHRITIS OF RIGHT HIP

  Assessment: Noted

  Plan:

- Operative plan per orthopedist

- No further pre-op testing indicated, but will get ECG in pre-op for new baseline.

- Recommend post-op DVT prophylaxis with ASA 81 mg BID for 4 weeks.

- Med holds as below

 

 HTN (HYPERTENSION)

  Assessment: Noted

  Plan:

- Hold HCTZ and losartan on DOS

 

 ESOPHAGEAL SPASM

  Assessment: Diet-controlled, has not used NTG in years

  Plan:

- OUtpatient fup

 

 HYPERLIPIDEMIA

  Assessment: Never started statin.

Plan:

-F/up with PCP

 

 

Patient Instructions:

The patient was provided the following PREOPERATIVE instructions:

 

PRIOR TO SURGERY

Stop all non-prescription vitamins, herbs, and supplements 1 week before surgery.

Continue all of your regularly scheduled medications

 

DAY OF SURGERY

Do not take your blood pressure medications (Hydrochlorothize and losartan) on the morning of surgery.

 

Inpatient Hip Replacement chart - Progress notes

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PROGRESS NOTES

Relevant Medical Problems:

OSA Risk:  no

Does pt use CPAP: no

Other Concerns Identified in PREOP H&P

Assessment and Plan:

XXX  is a 72 Y female is optimized for planned surgery.

Preliminary ASA Class: 2

The following studies have been ordered or are pending at the time of this visit: EKG to be done in pre-op

 

Patient Active Hospital Problem List:

 OSTEOARTHRITIS OF RIGHT HIP

  Assessment: Noted

  Plan:

- Operative plan per orthopedist

- No further pre-op testing indicated, but will get ECG in pre-op for new baseline.

- Recommend post-op DVT prophylaxis with ASA 81 mg BID for 4 weeks.

- Med holds as below

 

 HTN (HYPERTENSION)

  Assessment: Noted

  Plan:

- Hold HCTZ and losartan on DOS

 

 ESOPHAGEAL SPASM

  Assessment: Diet-controlled, has not used NTG in years

  Plan:

- OUtpatient fup

 

 HYPERLIPIDEMIA

  Assessment: Never started statin.

Assessment/Plan: XXX is a 72 Y female POD #0  Right Total Hip Arthroplasty (Direct Anterior Approach)

 

planned for same day discharge if meets all criteria and medically stable

 -Wound care:

            Keep dressing clean dry and intact. 

             Can shower over dressing. Keep surgical dressing on for 7 days then can remove and can let running water go over the incision when needed, then pat it dry.

            No Staples to remove

            No drain

           

-Activities:

            WBAT,  FROM ; no hip precautions

            PHYSICAL THERAPY eval

 

-Heme:

-Pain Control:

            Per PACU protocol, if admitted then

            IV Tylenol & Toradol 

            Oxycodone 5mg q4h prn

            Adductor Canal Catheter for Knee

           

-ID:

            IV Antibiotic: Ancef 2 gm before d/c today. If admitted can administer one more dose 8 hours after last dose

            Cx: none

 

-Resp:

            Encourage IS, Home with device

            Wean down O2 as able

            OSA Protocol if admitted:

 

-GI/GU:

            No foley

            Senna/Miralax

 

-Diet:

            Regular

 

-Dispo:

            Home with Home Health if meets Same Day Home Recovery Criteria or otherwise Sunrise Discharge

 

 

Foley - no foley

Antibiotics - prophylaxis x 24 hrs if admitted

DVT prophylaxis - Start/continue pharmacologic prophylaxis 

Beta Blockers - not indicated

 

Inpatient care for this patient is medically necessary if admitted to monitor for: adequate pain control and response to medication and/or adjustments, postop care and treatment with: IV pain medication, IV antibiotics, medication titration and physical therapy

Inpatient Hip Replacement chart- OP report

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OPERATIVE REPORT

 

Pre-Op Diagnosis Codes:

   OSTEOARTHRITIS OF RIGHT HIP

 

Post-Op Diagnosis Codes:

   OSTEOARTHRITIS OF RIGHT HIP

 

Procedure(s) (LRB):

HIP REPLACEMENT ANTERIOR APPROACH TOTAL (Right)

 

 Anesthesia Type:

Spinal

 

Findings:

     Severe DJD right hip

  

Severe osteoarthritis of the hip that has failed nonsurgical management

 

Procedure details:

Patient was met in the preoperative holding area.  History and physical was performed.  Signed informed consent was obtained.  The operative extremity was marked.  The anesthesia team performed a spinal anesthetic in the preoperative area.  Patient was then taken into the operating room.  Briefing was performed confirming patient name laterality and intended procedure, all members of the team were in agreement.  A radiological timeout was performed.  Preoperative antibiotics and TXA were given.  The patient was then transferred to the Hana table and secured in a regular fashion.  Preoperative fluoroscopic imaging was performed to replicate the standing AP pelvis.  The operative extremity was then prepped and draped in the usual standard fashion.

 

A 9 cm incision was made lateral and distal to the ASIS.  Soft tissue was carefully dissected until the TFL fascia was reached.  The TFL fascia was sharply incised.  The interval between the TFL and the sartorius was bluntly developed.  The lateral femoral circumflex vessels were identified and coagulated using the electrocautery and a clamp.

 

Capsulotomy was made and the flaps were tagged for later repair.  A neck cut was made using an oscillating saw.  Gross traction and 50 degrees of external rotation were placed on the leg via the Hana table. The femoral head was removed using a power corkscrew.  The acetabulum was exposed.  The labrum and the pulvinar were removed using electrocautery.  The acetabulum was sequentially reamed starting at approximately 3 mm below the measured head size. The final cup was then impacted into position the final cup position was confirmed using fluoroscopic imaging.  2 acetabular screws were then placed for additional fixation. 

 

The polyethylene liner was placed in the acetabulum and impacted into place.

 

Attention was then turned to the femur.  Gross traction was removed the femur was then externally rotated to 90 degrees.  Additional release of the capsule near the calcar was performed.  The femur was then rotated to 120 degrees. The leg was then extended and adducted.  The capsule along the superior neck was then released.   Once adequate exposure of the femur was obtained we began with canal preparation. A box osteotome was used to remove lateral bone.  A rongeur was then used to remove any additional lateral bone.  A starter broach was manually placed into the canal to both identify the canal and to remove additional bone.  The canal was then sequentially broached. The final broach was rotationally stable and did not go further into the canal when impacted.  Trial reduction was performed.  Imaging confirmed appropriate broach size. 

 

Leg lengths were evaluated using fluoroscopy with a drop rod placed across the lesser trochanters

 

The hip was then dislocated and all implants were removed.  The final stem was impacted into place.  The final ceramic head was placed onto the trunnion after the trunnion was cleaned and the hip was re-reduced. Final fluoroscopic images confirmed appropriate placement of the femoral stem.  The wound was then filled with dilute Betadine solution and this was allowed to sit for 3 minutes.  The hip was injected with the Dalury cocktail in both the deep and subcutaneous tissues.

 

The capsule was then repaired with #1 Polysorb sutures.  The fascia was repaired with #1 polysorb sutures.  Deep fat was closed with 0 Polysorb sutures. The dermis was closed with 3-0 Polysorb sutures.  The skin was closed with subcuticular 3-0 Biosyn and skin glue.  A Aquacell dressing was placed.

 

Patient was then transferred to the gurney and taken to the PACU in stable condition.

  

Estimated Blood Loss:

   250 cc

 

Fluids:

   See anesthesia record

 

Drains:

  none

 

Complications:

   (1) No - Per Surgeon/Proceduralist  Comments: none

(2) No - Per Anesthesia Provider  Comments: none

 

Specimens:

* No specimens in log *

Inpatient Hip Replacement chart - Key

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CODES

MS-DRG – 470

ICD CODES

 

M16.11 - Unilateral primary osteoarthritis, right hip

D69.2 - Other nonthrombocytopenic purpura

E78.5 - Hyperlipidemia, unspecified

I10 - Essential (primary) hypertension

K22.4 - Dyskinesia of esophagus

J45.909 - Unspecified asthma, uncomplicated

Z85.828 - Personal history of other malignant neoplasm of skin

Z88.5 - Allergy status to narcotic agent

Z88.1 - Allergy status to other antibiotic agents

Z88.6 - Allergy status to analgesic agent

Z88.8 - Allergy status to other drugs, medicaments and biological substances

 

PCS CODES

 

0SR904A - Replacement of Right Hip Joint with Ceramic on Polyethylene Synthetic Substitute, Uncemented, Open Approach

Covid-19 April 1, 2022 Updates

New Diagnosis Codes Vaccination Status

Z28.310 - Unvaccinated for Covid-19

Z28.311 - Partially vaccinated for Covid-19

Z28.39 - Other underimmunization status

Code Z28.310, Unvaccinated for COVID-19

 ➢ not received at least one dose of any COVID-19 vaccine 

Code Z28.311, Partially vaccinated for COVID-19 

➢ has received at least one dose of a multi-dose COVID-19 vaccine but not the full set of doses to meet CDC’s definition of “fully vaccinated” 

Code Z28.39, Other Underimmunization status 

➢ patient is delayed or lapsed in getting other non-COVID vaccines 

➢ includes delinquent immunization status and lapsed immunization schedule status 

More information on the non-COVID-19 vaccine schedule is available here:

 https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html

Inpatient Pregnancy Chart 1 DS

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DISCHARGE SUMMARY

Diagnoses:

•             (Principal) NORMAL DELIVERY     

•             PRECIPITATE LABOR         

•             SECOND DEGREE PERINEAL LACERATION                

                                2nd degree episiotomy cut  

•             BREAST FEEDING MOTHER            

•             RH NEGATIVE     

                                Received rhogam for bleeding 1st tri 8/2/21

•             MAJOR DEPRESSIVE DISORDER, RECURRENT EPISODE, IN FULL REMISSION              

                                On celexa

Male

Delivery Type: Vaginal, Spontaneous

 

Birth date/time:               13/11/21              2:25 AM 

Living status: Living

Sex: Male

Apgar 1min: 8    Apgar 5min: 9  

Weight: 3240 g

 Labor and Delivery Complications

Labor Complications: None

Shoulder Dystocia: No 

 

Primary Procedures:

Male

Delivery Type: Vaginal, Spontaneous 

 

Secondary Procedures:

Male

Placenta Removal: Expressed

Anesthesia:

Method: Local

Local Medication Used: Lidocaine 1%

Volume (mL): 10                                              

Episiotomy/Lacerations

Episiotomy: Median        Repaired with: 3-0 Polysorb, 2-0 Polysorb

Episiotomy Laceration Comment: Anal sphincter evaluated by MD Chu, found intact

Perineal lacerations: None            

 

Summary of Hospital Course:

Patient was admitted for: Active Labor

Her intrapartum course was: significant for precipitous delivery 

Her post delivery course was: unremarkable

Complications: None

 

Subjective:

This patient is known to me as I attended her birth. No unusual complaints. Rhogam given. Seen by LSW this AM.

Pain relieved with medications

Breastfeeding   Experienced breastfeeding mother, no complaints

Bleeding normal

Voiding  normal

Diet and Bowel function  tolerating a regular diet

Mobility Walking without difficulty

 

Physical Exam at discharge:

BP 106/50  | Pulse 73  | Temp 99.2 °F (37.3 °C)  | Resp 18  | Ht 1.778 m (5' 10")  | Wt 76.8 kg (169 lb 5 oz)  | SpO2 98%  | Breastfeeding Yes  | BMI 24.29 kg/m²

 

General Appearance:  Alert, well appearing and in no distress

Breasts:   Soft

Abdomen:  soft, fundus well contracted and nontender

Perineum:  sutures intact

Extremities:  no tenderness in the calves or thighs and no significant edema

 Birth Control Plan: hx infertility 

Condition on discharge:

Patient is medically stable for discharge and agrees with the plan of care.

 

Discharge Disposition:

Discharged home

Inpatient Pregnancy Chart 1 H&P

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H&P

 

HPI:

AABB is a 43 Y G4P1021 at 38w3d who presents to triage for painful/regular contractions that started yesterday but became more intense at midnight today. +FM, denies LOF, VB. Accompanied by FOB. Pt arrived to the hospital nearly complete (9.5 with a slight right cervical lip) and spontaneously began to bear down within 10 minutes of my initial evaluation.

 

Antenatal issues include pregnancy achieved by IVF, prediabetes in pregnancy, GBS carrier. Pt also Rh negative, and received Rhogam twice in pregnancy--once in first tri for bleeding, and again at 30w6d. Notable OB hx includes delayed PPH QBL 840mL.

 

Past Medical History / Past Surgical History:

Active Ambulatory Problems

                Diagnosis            

•             *OTHER MR # EXISTS       

•             SECONDARY FEMALE INFERTILITY             

•             DIMINISHED OVARIAN RESERVE

•             DIMINISHED OVARIAN RESERVE, ADVANCED MATERNAL AGE     

•             MAJOR DEPRESSIVE DISORDER, RECURRENT EPISODE, IN FULL REMISSION            

•             RH NEGATIVE   

•             GENETIC DISORDER CARRIER      

•             PREDIABETES    

•             SUPERVISION HIGH RISK PREGNANCY, RESULTING FROM ASSISTED REPRODUCTIVE TECHNOLOGY              

•             PRENATAL INTAKE INTERVIEW  

•             ANTENATAL SCREENING

•             PREDIABETES IN PREGNANCY    

•             LEUKOPENIA     

•             LOW LYING PLACENTA WO HEMORRHAGE           

 

Additional diagnoses from the Past Medical History section

Diagnosis            

•             ANXIETY                

•             FEMALE INFERTILITY       2017

•             HX OF DEPRESSION         2000

•             HX OF VARICELLA              

•             MIGRAINE          1993

•             SEASONAL ALLERGIES     

 

Past Surgical History:

Procedure                          

•             DILATION AND CURETTAGE        

 

Family History

Problem               Relation              

•             Alcohol Abuse   Maternal Grandfather    

•             Depression         Maternal Grandmother  

  

Social History

Tobacco Use

•             Smoking status: Never Smoker

•             Smokeless tobacco:        Never Used

•             Tobacco comment:

Vaping Use

•             Vaping Use:        Never used

Substance Use Topics

•             Alcohol use:       No

                                Alcohol/week:  2.0 standard drinks

                                Types:   2 Glasses of wine per week

                                Comment: pregnant

•             Drug use:             No

                               

E-Cigarettes/Vaping

                Questions           Responses

                E-Cigarette/Vaping Use Never User

 

 E-Cigarette/Vaping Substances

                Questions           Responses

                Nicotine               No

                THC        No

                CBD        No

 

Allergies:

Mushroom - dietary and Penicillins class

 

Active Meds:

Medication

•             Citalopram (CeleXA) 20 mg Oral Tab

•             Aspirin (ECOTRIN LOW STRENGTH) 81 mg Oral TBEC DR Tab

 

ROS: Noncontributory except for pregnancy symptoms as above

 

Vitals:

BP: 125/61

Temp: 98.1 °F (36.7 °C)

Heart Rate/Pulse: 74

Resp: 18

Last weight recorded at last prenatal appointment:

RECENT WEIGHT READING(S)

03/19/22              76.8 kg (169 lb 5 oz)

 

Estimated body mass index is 24.29 kg/m² as calculated from the following:

  Height as of this encounter: 1.778 m (5' 10").

  Weight as of this encounter: 76.8 kg (169 lb 5 oz).

 

Physical Exam:

General: well developed, well nourished

Uterus: gravid , nontender

Vulva: no lesions

Extremities: nontender, minimal edema

 

Cervical exam:

Dilation (cm): 9.5 CM

Effacement (%): 100 %

Station: -1

Bag intact, Sutures palpated

 

Uterine Activity:

Contraction Frequency (min): 2-4

 

Fetal assessment:

Baseline Fetal Heart Rate (Baby A): 135

Variability: Moderate

Accelerations: 15X15

Decelerations: Variable (HR audible in 90s)

 

Membranes and Fluid:

Membrane Status: Ruptured

Fluid Characteristics: Clear

Fluid Amount: MODERATE

 

Patient assessment:

38w3d multip normal IUP, precipitous labor entering second stage

Cat II FHT for deep variable decels/prolonged decels

 

Active Hospital Problems

                Diagnosis              

•             PRECIPITATE LABOR         

•             GROUP B STREP CARRIER IN PREGNANCY               

•             SECOND DEGREE PERINEAL LACERATION                

                                2nd degree episiotomy cut

 

•             BREAST FEEDING MOTHER            

•             PREDIABETES IN PREGNANCY      

                                Intake FBS wnl however hga1c 5.8 --> early glucola ordered [ x]  116

[x ] repeat GTT at 24 wk = 59 

•             SUPERVISION HIGH RISK PREGNANCY, RESULTING FROM ASSISTED REPRODUCTIVE TECHNOLOGY                

                                Prediabetes, IVF pregnancy.  AMA

 Egg retrieval at 41 y/o.   Euploid by pgs, another boy

Discussed management including bASA, 39 week induction. Early GDM screening.  Strict kick counts 3rd trimester.

[X] baseline PIH labs -> 9/4 wnl

[X] hga1c 5.8 (prediabetes), fbs (wnl)--> early 1 hr glucola WNL, repeat at 24 wk

 

 Partner Erik

1.5 y/o son Sam

Completed covid vaccination

Plans breastfeeding again

[x ] tdap [x] rhogam

 

•             RH NEGATIVE     

                                Received rhogam for bleeding 1st tri 8/2/

[ ] rhogam 28-30 weeks, prn 

•             MAJOR DEPRESSIVE DISORDER, RECURRENT EPISODE, IN FULL REMISSION              

                                On celexa

 

 Based on the clinical risk factors present at admission the patient's risk of Postpartum Hemorrhage is:  medium

 

Fetal Heart Rate Surveillance: Patient is ineligible for intermittent auscultation

 

Covid testing:

We discussed risks, benefits, and alternatives of testing, and risks and benefits of the alternatives. Testing recommended and accepted.

 

Plan:

Admit in Active Labor (regular contractions with cervical change)

 #Labor

Precipitous delivery

 

 #Maternal

Vital signs stable

 

 #ID

GBS pos, however no prophylactic abx administered intrapartum

 

#Fetal

Cat II

 

#Pain

Declines pharmacologic pain management

 

#Contraception

Hx infertility

 

#Feeding

Breast

 

I have reviewed the clinical diagnoses listed below which were considered in the care of this patient.  At the time of this visit there are no changes in these conditions unless otherwise noted.  The patient will be advised to follow up after discharge with their PCP or appropriate specialist as treatment warrants. 

 

Clinical Diagnoses: 

                MAJOR DEPRESSIVE DISORDER, RECURRENT EPISODE, IN FULL REMISSION (Chronic)