This is a case study. Please answer the 5 questions below in bold letters. Week 2 Case2
LOCATION: Inpatient, Hospital
PATIENT: Sorrento Hernandez
PHYSICIAN: Rolando Ortez, MD
CHIEF COMPLAINT: Prematurity with respiratory difficulty.
HISTORY: This is a 30 weeks, 1 day gestation female infant with birth weight of 1808
grams. Mom is a 26-year-old gravida 2, now para 2 mom. Her blood type is O positive,
antibody negative, RPR nonreactive, rubella immune, hepatitis B surface antigen
negative, HIV negative, GC negative, chlamydia negative, Group B Strep status
unknown. Moms MSAFP was elevated at 14.2 with a 1:180 risk for Down syndrome. No
neural tube defect. No amniocentesis performed. She was on prenatal vitamins. First
pregnancy went to 35 weeks without complications. He is doing well at 10 years of age;
however, he does have Noonan syndrome.
Although this is my first visit, I did attend the delivery of the baby. Spontaneous cry
noted, and Apgar score was 7 at 1 minute, with points off for color, tone, and grimace,
and then at 5 minutes, Apgar score of 8 with points off for grimace and tone. The infant
was then brought back to the NICU for further management. Babys face does look
somewhat dysmorphic with concerns for Noonan syndrome; very small posterior
pharyngeal space was noted with difficult intubation, and after several attempts, the
anesthesiology department was called and the infant was intubated. Throughout the
intubation attempts, standard procedure was followed and the baby tolerated the
attempts very well. The intubation was performed because of concerns of
hypoventilation noted on exam with decreased breath sounds bilaterally as well as
increased work of breathing.
Umbilical artery catheter was also placed without difficulty. First blood sugar did come
back at 23, a peripheral IV was placed promptly, and 2 cc/kilo of D10 was given along
with placing the infant on D10 at 80 cc/kilo. Second blood sugar has come back
elevated. Chest x-ray is obtained, as well as abdominal films, and shows good
placement of the UAC at T7, and the endotracheal tube is also in good placement and
is a 3.02. The OG has been advanced. The lung fields do show significant granularity
present. No pneumothorax, no cardiomegaly. Blood gas is 7.32, PCO2 of 50, PO2 of 100
and that is on a setting of 22/4, rate of 60% and 80% FIO2.
PHYSICAL EXAMINATION: Currently is intubated, her weight is 1808 grams. OFC is
30.5 cm, length is 39.4 cm. Heart rate is in the 130s to 140s. Respiratory rate is at 60 on
O2 sat. is in the mid 90s. Blood pressure is right arm, 67/34 with a mean of 46, right leg
67/32 with a mean of 44.
Mild splitting of the cranial sutures is noted along with open posterior and anterior
fontanel. Red reflex ×2. Eyes appear to have hypertelorism present and questionable
epicanthal folds along with some down-slanting palpebral fissures. Ears appear to be
low set and posteriorly rotated. Palate is intact. There is a small retropharyngeal space.
Clavicles are intact. I do not appreciate any webbing on the neck. Nipples, questionable,
mildly wide spaced. Lungs at this time are clear to auscultation. She has good
symmetric aeration; minimal chest rise noted. Prior to that, lungs were remarkable for
decreased aeration with crackles. Heart is regular rate and rhythm, no murmurs noted.
Femoral pulses palpable, cap refill less than 2 seconds. Abdomen is without
hepatosplenomegaly, three-vessel cord. Genitourinary: Normal female. Extremities:
Adequate range of motion, no contractures or hip abnormalities noted. Skin is ruddy in
complexion. Neurologic Exam: Hypotonia diffusely.
Developmental assessment: No breast buds, soft pinna with minimal recoil, no creases
on the feet, consistent with a 30-week preterm infant.
1. Premature female infant.
2. Respiratory distress due to hyaline membrane disease as well as a component of
hypoventilation secondary to maternal elevated magnesium.
3. Observation for sepsis.
4. Maternal hypermagnesemia with elevated magnesium in the infant as well.
5. Family history of Noonan syndrome in an older brother.
PLAN: Admission to the NICU. Intubation has been performed, and she is on
mechanical ventilation. Will go ahead with the surfactant therapy per protocol, close
cardiorespiratory monitoring and monitoring of blood gases and chest x-rays. NPO
status, and she will be on D10 with 0.94 mEq of calcium gluconate added to run at 80
cc/kilo/day. Ampicillin and gentamicin administered per protocol. Blood cultures have
been obtained as well as a CBC, magnesium level, and further glucose monitoring. She
will also need chromosomal testing, and that will be drawn in the near future. Also, head
ultrasound at 6 days of life will need to be performed. I have not talked with the mother.
Her condition has deteriorated post cesarean section and she is not available at this
time. I have talked in detail with the father in regard to the above, including possibility of
further deterioration prompting transfer to another facility. All of his questions have been
Abstracting & Coding Questions:
1. Was this the initial or subsequent visit?
2. Does the age of the patient affect CPT code selection?
3. What two factors affect diagnosis code assignment?
4. What CPT code(s) would be reported for this case?
5. What ICD-10-CM code(s) would be reported for this case?