Hypothermia, not associated with low environmental temperature
ICD-10 R68.0 is a billable code used to indicate a diagnosis of hypothermia, not associated with low environmental temperature.
Hypothermia is defined as a body temperature below 95°F (35°C) that can occur due to various medical conditions rather than exposure to cold environments. This condition can arise from metabolic disorders, endocrine dysfunctions, or as a side effect of certain medications. Symptoms may include confusion, shivering, slurred speech, slow breathing, and fatigue. In clinical settings, hypothermia can be identified through physical examination and laboratory tests that reveal low body temperature and altered mental status. It is crucial to differentiate this type of hypothermia from environmental causes, as the management and underlying conditions may differ significantly. The diagnosis requires careful assessment of the patient's history, including any recent illnesses, medications, or metabolic conditions that could contribute to the hypothermic state. Laboratory findings may include electrolyte imbalances, altered glucose levels, and abnormal thyroid function tests, which can help identify the underlying cause.
Detailed patient history, including medication review and metabolic assessments.
Patients with chronic illnesses, endocrine disorders, or those on medications affecting thermoregulation.
Ensure documentation reflects the clinical context and any contributing factors to hypothermia.
Acute care notes must include vital signs, temperature readings, and immediate interventions.
Patients presenting with altered mental status or confusion, requiring rapid assessment.
Document any immediate treatments provided and the patient's response to interventions.
Used when a patient presents with hypothermia and requires immediate evaluation.
Document vital signs, temperature, and any interventions performed.
Emergency medicine providers should ensure thorough documentation of the patient's condition and treatment.
Common causes include metabolic disorders like hypothyroidism, drug effects from sedatives or antipsychotics, and acute illnesses such as sepsis or severe infections.
