[Verified Answer]: code this case Principle Problem:…

code this case Principle Problem: Premature Infant of 31 weeks gestation Initial visit Initial visit on this patient who is receiving intensive observation, monitoring and support after being requested to attend the delivery by OB and provide stabilization for the infant. Mode of Delivery: C-Section Resuscitation: was needed. See completed documentation in the Resuscitation note. Apgar Scores: 3 (1 min)/ 7 (5min) / (10min) Baby born at outside hospital: No Vascular Access on Admission: PIV Current Feedings/Fluids: NPO Respiratory Support on Admission: CPAP Patient Family and Prenatal history: as documented by nursing staff. No additions or changes. ROS 10 system Negative except for respiratory. See completed documentation in Resuscitation note. Vitals: Temperature: 98.4°F Pulse: 174 Respirations: 48 Blood Pressure: 50/38 SpO2: 94% Weight: 1590g Length: 41cm Head Circumference: 28.5cm Physical Examination General: alert, in mild distress and AGA Head: normocephalic and atraumatic, anterior fontanelle open and flat and molding Eyes: pupils equal, round, and reactive to light and positive red reflex bilaterally ENT: Moist mucous membranes, normal set ears with no pits or tags, patent nares, palate intact, oropharynx clear Neck: neck supple with full active range of motion, clavicles intact Chest: tachypneic and grunting Cardiac: Regular rate and rhythm, normal S1 and S2, no murmur, normal pulses, warm and well perfused Abdomen: Soft, nontender, and nondistended; normoactive bowel sounds; no mass or hepatosplenomegaly palpated Back: spine intact GU: normal male external genitalia, patent anus, uncircumcised and testes descended bilaterally Musculoskeletal: normal muscle bulk with no contractures and appropriate range of motion Skin: No rashes or lesions and pink Neurologic: spontaneous movement of all extremities Assessment/Plan: 1. Premature Infant of 31 weeks gestation 2. Respiratory Distress Syndrome- Admitted on CPAP, follow, CXR pending No surfactant given. 3. Dichorionic diamniotic twin gestation (Twin B)