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The patient is a 38-year-old with a history of left breast malignancy (Her2-negative) status post modified left radical mastectomy, antineoplastic and radiation therapy. She has previously undergon...
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A patient with central nervous system 1a, B-cell acute lymphoblastic leukemia (B-ALL) is admitted for intrathecal consolidation chemotherapy. Immediately following chemotherapy, per protocol, an en...
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A newborn delivered at term with Apgar scores of 9 and 9, was monitored for withdrawal symptoms due to intrauterine exposure of prescribed maternal Subutex®. Neonatal abstinence syndrome (NAS) mon...
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A 39-week old infant was born via spontaneous vaginal delivery to a mom who had a history of marijuana use, and subsequently stopped using once she found out about the pregnancy. Because of the his...
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Quality measures at our facility may be affected when a patient is receiving palliative care and the present on admission (POA) indicator “N” (No) is reported. We are seeking official guidance ...
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A patient arrived at the Emergency Department (ED) with vaginal bleeding at 18 to 19 weeks gestation and had a spontaneous vaginal delivery of twin A, in the ED. Upon the initial assessment in Labo...
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A patient presents at 41-weeks of gestation and had an uncomplicated vaginal delivery. She was diagnosed with bacterial vaginitis and was treated with Flagyl. How should bacterial vaginitis in preg...
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A 28-year-old pregnant patient with three previous cesarean deliveries was admitted due to placenta increta at 15 weeks 4 days gestation. The patient was counseled regarding the risks of continuing...
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This same patient underwent gravid total abdominal hysterectomy and bilateral salpingectomy with fetus in situ. During the procedure, the uterine vessels were clamped. The placenta was found to be ...
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What is the appropriate ICD-10-CM code assignment for a diagnosis of “tight nuchal cord” on the newborn record? Does “tight” nuchal cord” indicate “with compression” or must the provi...
A tight nuch...