Josie is a full term newborn infant who weighed approximately 3000 grams when she was born. She is 19 inches in length

Question

Josie's mom is an alcoholic who drank throughout the pregnancy and the pediatrician was asked to examine Josie for problems associated with her mother's alcohol use. On physical exam, Josie is not really small or light for dates, but she does show signs of fetal growth retardation such as peeling skin and loss of subcutaneous tissue. She has decreased muscle tone, small eyes with large epicanthal folds, small head and upper jaw with a smooth, thin upper lip. There was no appreciable heart murmur. Now, Josie is healthy enough to be discharged in the care of her grandmother who was given temporary custody of Josie until her mother completes a court-ordered stay at an alcohol rehab facility. The grandmother was instructed to see Josie's pediatrician in three weeks.

Dx: Fetal exposure to alcohol, IUGR

First-listed/principal diagnosis: ________
Secondary diagnoses: ________
Fill in the blank with correct word.

Answer 1

First-listed/principal diagnosis: ________
Answer: Single liveborn infant, born in hospital – delivered vaginally – Z38.00

Secondary diagnoses: ________
Answer: Newborn affected by mother's alcohol use – P04.3, IUGR – P05.2