My question is on this case shown below regarding the diagnosis OP position and asynclitic and Insufficient Epidural.
At the end the provider stated PT temp 100 degrees F skin, pt tachycardic throughout the procedure plan to continue abx for 24 hours. On these I came up with O75.2 for temp and R00.0 for
tachycardic but I could not find O code
Pre-operative Diagnosis: Patient is an 29 y.o. G1P0 at 40w1d persistent cat II tracing, remote from delivery
Principal Problem:
Persistent cat II tracing, remote from delivery
Thick meconium
OP position and asynclitic
Insufficient epidural
Post-operatIve Diagnosis:
same
Procedure:
Primary Low Transverse Cesarean Section
After informed consent was obtained the patient was taken to the operating room where the dosing of Epidural anesthesia was found to be inadequate. Pt was then prepared and draped in the normal sterile fashion in the dorsal supine position with a leftward tilt. A Time Out was held and the patient and procedure were confirmed. General anesthesia was induced and immediately a Pfannenstiel skin incision was then made with the scalpel and carried through to the underlying layer of fascia. The fascia was incised in the midline with the scalpel and extended laterally bluntly. The rectus muscles were then separated in the midline bluntly, and the peritoneum identified, tented up, and entered blunt dissection. The peritoneal incision was then extended superiorly and inferiorly bluntly with good visualization of the bladder. The bladder blade was then inserted, a bladder flap was not created. The lower uterine segment was incised in a transverse fashion with the scalpel. The uterine incision was then extended laterally digitally. The bladder blade was removed, then the fetus was noted to be in cephalic presentation. There was difficulty elevating the fetal head out of the pelvis and the RN had to glove and perform a vaginal exam to apply pressure to gently elevate the head out of the pelvis so the head could be reached and brought to the incision. Gentle fundal pressure was applied once the head was brought into the incision and infant delivered atraumatically. Baby was noted to be LOP position. The cord clamping was immediately double clamped and cut. The neonate was handed off the field to the awaiting neonatal team. Cord gases and blood collected. The placenta was then removed, the uterus was exteriorized, and cleared of all clots and debris. The fibroid was noted to be approx 7x8cm right fundal. The uterine incision was repaired with 1 Vicryl in a running, locked fashion. A second layer of the same suture was used in an imbricating fashion to obtain excellent hemostasis. The abdominal cavity was irrigated and the uterus was replaced into the abdomen. The gutters were cleared of all clots and debris the hysterotomy site was noted to be hemostatic. The fascia was then reapproximated with 1 Vicryl in a running fashion. The subcutaneous tissue was closed with 3-0 vicryl in a running fashion. The skin was closed with 4-0 Monocryl in a subcuticular fashion noting excellent hemostasis. Sponge, lap and needle counts were correct times two. Mepilex placed over incision
Of note, per anesthesia, Pt temp 100 degrees F skin temp, pt tachycardic throughout procedure, plan to continue abx x24 hrs
Postpartum hemorrhage (EBL >1000mL): None
Complications: None; patient tolerated the procedure well.
Disposition: PACU - hemodynamically stable.
Condition: stable
Follow up: will follow pt while inpatient
Patricia Nelson-Boruch CPC CEMC
At the end the provider stated PT temp 100 degrees F skin, pt tachycardic throughout the procedure plan to continue abx for 24 hours. On these I came up with O75.2 for temp and R00.0 for
tachycardic but I could not find O code
Pre-operative Diagnosis: Patient is an 29 y.o. G1P0 at 40w1d persistent cat II tracing, remote from delivery
Principal Problem:
Persistent cat II tracing, remote from delivery
Thick meconium
OP position and asynclitic
Insufficient epidural
Post-operatIve Diagnosis:
same
Procedure:
Primary Low Transverse Cesarean Section
After informed consent was obtained the patient was taken to the operating room where the dosing of Epidural anesthesia was found to be inadequate. Pt was then prepared and draped in the normal sterile fashion in the dorsal supine position with a leftward tilt. A Time Out was held and the patient and procedure were confirmed. General anesthesia was induced and immediately a Pfannenstiel skin incision was then made with the scalpel and carried through to the underlying layer of fascia. The fascia was incised in the midline with the scalpel and extended laterally bluntly. The rectus muscles were then separated in the midline bluntly, and the peritoneum identified, tented up, and entered blunt dissection. The peritoneal incision was then extended superiorly and inferiorly bluntly with good visualization of the bladder. The bladder blade was then inserted, a bladder flap was not created. The lower uterine segment was incised in a transverse fashion with the scalpel. The uterine incision was then extended laterally digitally. The bladder blade was removed, then the fetus was noted to be in cephalic presentation. There was difficulty elevating the fetal head out of the pelvis and the RN had to glove and perform a vaginal exam to apply pressure to gently elevate the head out of the pelvis so the head could be reached and brought to the incision. Gentle fundal pressure was applied once the head was brought into the incision and infant delivered atraumatically. Baby was noted to be LOP position. The cord clamping was immediately double clamped and cut. The neonate was handed off the field to the awaiting neonatal team. Cord gases and blood collected. The placenta was then removed, the uterus was exteriorized, and cleared of all clots and debris. The fibroid was noted to be approx 7x8cm right fundal. The uterine incision was repaired with 1 Vicryl in a running, locked fashion. A second layer of the same suture was used in an imbricating fashion to obtain excellent hemostasis. The abdominal cavity was irrigated and the uterus was replaced into the abdomen. The gutters were cleared of all clots and debris the hysterotomy site was noted to be hemostatic. The fascia was then reapproximated with 1 Vicryl in a running fashion. The subcutaneous tissue was closed with 3-0 vicryl in a running fashion. The skin was closed with 4-0 Monocryl in a subcuticular fashion noting excellent hemostasis. Sponge, lap and needle counts were correct times two. Mepilex placed over incision
Of note, per anesthesia, Pt temp 100 degrees F skin temp, pt tachycardic throughout procedure, plan to continue abx x24 hrs
Postpartum hemorrhage (EBL >1000mL): None
Complications: None; patient tolerated the procedure well.
Disposition: PACU - hemodynamically stable.
Condition: stable
Follow up: will follow pt while inpatient
Patricia Nelson-Boruch CPC CEMC