Inpatient sample charts / Sample Inpatient cases / Inpatient DRG coding / DRG coding sample charts
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)
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