Inpatient Case 1 – Patient Name: Mary Williams History of Present…

Inpatient Case 1 – Patient Name: Mary Williams History of Present… Inpatient Case 1 – Patient Name: Mary WilliamsHistory of Present Illness (HPI): This is a 69-year-old female with a previous myocardial infarction and known hypertension.  The patient started complaining of cough, chills, and fever about 4 days prior to admission.  One day prior to admission, she started to complain of progressive dyspnea associated with pain in her chest.  She went to the emergency department (ED) and was noted to be extremely dyspneic and wheezing.  She was given an aerosol treatment with good response.  However, chest x-ray showed evidence of bilateral lower pneumonia with a PO2 of 66 and white blood cell count of 12,400, for which admission was advised.  The patient had been taking Methyldopa 500 mg b.i.d., Ascriptin one tablet daily, Transderm Nitro 5 once daily, Capoten 30 mg b.i.d., and Lanoxin 0.725 mg daily.  The patient had an inferior wall myocardial infarction 10 months ago. She is known to have chronic anxiety problems and had been under the care of the mental hygiene clinic. Physical examination: Revealed a well-developed, well-nourished female whose respirations improved since the aerosol therapy was given.  Blood pressure is somewhat elevated.  Respirations 24. Pulse 110/minute.  HEENT: Unremarkable. No carotid bruits.  No distended neck veins.  Chest: No deformity.  Equal expansion. Lungs: Crepitant rales over the lower half of end hemithorax.  No wheezing. No pericardial or pleural rub noted. Heart: Regular rhythm. No murmurs. Abdomen: Soft. Liver, spleen, and kidneys not enlarged. No tenderness. Extremities: No clubbing. No cyanosis. Peripheral pulses strong and equal. Rectal: Deferred. Impression: Lobar pneumonia. Previous inferior wall myocardial infarction. Hypertension. Chronic anxiety. Plan: After appropriate cultures are obtained, the patient will be empirically started on Kefzol. Nasal oxygen will be administered. Patient will be hydrated, and aerosol therapy will be continued. Laboratory data and hospital course: Sputum smear showed moderate white blood cells, many epithelial cells, and many mixed respiratory microflora.  Sputum culture showed normal growth.  Blood cultures after 10 days showed no growth.  Chest x-ray report revealed mild congestive cardiac failure pattern. Significant improvement in congestive heart failure noted on second x-ray but no complete resolution, although the pneumonia has resolved.  EKG showed right bundle branch block with old inferior myocardial infarction, left ventricular strain; no change when repeated prior to discharge.  The patient’s previous medications were continued during her hospitalization including her anti-anxiety medication Fluozetine, Methyldopa, Ascriptin, Capoten, and Lanoxin for her angina, CHF, and hypertension.  After cultures were obtained, she was empirically started on intravenous Kefzol.  Because of initial bronchospasm, she was also started on aerosolized bronchodilator therapy consisting of Alupent.  She remained afebrile during her stay in the hospital. She had no further wheezing after 24 hours but continued to have crepitant rales in both bases.  She had one episode of mild angina pains relieved by nitroglycerin during her stay.  With improvement in her respirations and x-ray findings, she was discharged.  Her BP was 154/110 on discharge, but this is not considered unusual because her BP is quite unstable as an outpatient, with variable high and low readings.  This will, however, be followed up in the office. Final Diagnoses: Bilateral lobar pneumonia Angina and Old myocardial infarction. Hypertension. Chronic anxiety. Congestive heart failure not related to hypertension. Codes assigned are:Principal diagnosis: J18.9Additional diagnoses: I25.2, I20.9Are these the correct codes per the clinical documentation and ICD-10-CM coding guidelines?  Is J18.9 the correct principal diagnosis per the clinical documentation and UHDDS guidelines? Are there any missing ICD-10-CM codes? Remember you are looking for accuracy and completeness in the ICD-10-CM codes assigned.    Health Science Science NursingHIT 205Share QuestionEmailCopy link Comments (0)

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