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This is a female, gestational age 39 weeks, days, born by cesarean section in this facility, 11/01/21 05:45. The patient has bailout vomiting and a heart murmur. First time seeing patient in hospital. EXAM;VS T 37.1(ax), p150, R45, BP75\50, oxygen saturation 99% in room air.height, weight and head 50th percent. Nasgastric tub is placed and iv fluid administered. Echocardiogram demonstrates heart murmur, which medically managed. A chromosomal abnormality is suspected and a karyotype is done. Trisomy 21 diagnosis. DX: Trisomy 21 (Down syndrome) and neonatal Jaundice. Recommendations: Newborn has neonatal jaundice, and Trisomy 21. Consultation with dermatologist GI specialist requested. CODE THE E/M CODE AND ANTmY OTHER PROCEDURES FOR THIS CASE FROM CPT BOOK AND ADD MODIFIER IF APPLICABLE
SCIENCE
HEALTH SCIENCE
NURSING
MCCG 240-001

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