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7.28.  The following documentation is from the health record of a...

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7.28.  The following documentation is from the health record of a...

7.28. 

The following documentation is from the health record of a 17-year-old male patient.

History of Present Illness: The patient is a 17-year-old white male who was brought to the emergency department after being found passed out in the town park. The patient was in restraints and accompanied by two police officers. The patient was combative and aggressive, threatening physical harm to himself as well as the physician and hospital staff. The patient has a long history of alcohol and drug abuse, was in the local treatment center, and walked off campus two days ago.

Allergies: NKDA

PMH: Oppositional defiance disorder (ODD) drug and alcohol dependence, aggressive behavior

Family History: Noncontributory

ROS: As above

Physical Examination: Vital signs: Temp. 100.1 degrees; BP 144/88 mm Hg; General: Alternating between lethargy and combativeness; HEENT: Pupils pinpoint, 1 mm bilaterally; Skin: Cool, clammy to touch, feet and hands cold, slightly diaphoretic; Heart: Rate tachy, no murmurs; Lungs: Clear, respiratory rate 28 and shallow; Abdomen: Benign; Neurological: Mental status as above; follows commands inconsistently, responds to voice; Cranial nerves: Pupils as noted, gag intact; Motor: Moving all four extremities with equal power; Sensory: Responds to touch in all four extremities; deep tendon reflexes 13 throughout, but plantar reflexes down going bilaterally.

Laboratory: U/A shows 21 blood, done after Foley catheter was placed; drug screen positive for amphetamines; ETOH 45 mg/100 ml; ABG within normal limits; EKG sinus tachycardia

Hospital Course: Family was contacted, IV fluids were initiated, for dehydration and tachycardia and the patient was admitted to ICU with suicide protocol, Ativan 1 to 2 mg IV q. 2 hours p.r.n. He was maintained on soft restraints with checks every 15 minutes and monitored with telemetry and neuro checks through the night. By the morning he was no longer tachycardic. By hospital day three he was medically stable, but still saying he wants to "kill himself." Psychiatric consult requested; see dictated report.

Disposition: Discharge to psych. Psychiatric liaison service agreed to accept him in transfer to the inpatient adolescent psychiatric unit at children's hospital.

Discharge Diagnoses: 1. Drug overdose with amphetamines and alcohol

2. Suicide attempt

3. Continued verbalization of suicidal ideation

4. Alcohol intoxication

 

Which of the following code sets would be correct for this case?

a. T43.622A, T51.0X2A, R00.0, F19.20, F10.229, F91.3, E86.0, Y90.2, Z78.1

b. R00.0, T43.625A, F19.20, F10.229, F91.3, E86.0, Y90.2, Z78.1

c. T43.622A, T51.0X2A, R00.0, F19.10, F10.10, F91.3, E86.0, Y90.2

d. R00.0, T43.522A, T51.0X2A, F19.20, F10.229, F91.3, E86.0, Y90.2

 

 

 

7.38. 
The following documentation is from the health record of a 62-year-old male patient.

Discharge Summary

Admission Diagnosis: Transient ischemic attack, possible stroke

Final Diagnoses

1. Transient vertigo versus posterior circulation transient ischemic attack

2. Type 2 diabetes

3. Coronary artery disease status post coronary bypass grafting

4. Hyperlipidemia

Consultants: Neurology

History

This is a 62-year-old white male who was admitted through the emergency department with a variety of symptoms, somewhat vague, describing components of dizziness, double vision, slightly slurred speech, vague numbness and tingling of the upper extremities for two or possibly three days. He has had intermittent different episodes off and on over the past two to three months. The patient has several risk factors including coronary disease, hyperlipidemia, and he is a smoker. He was admitted with possible TIAs or CVA.

Hospital Course: After being admitted to the Intermediate Care Unit and Stepdown Unit for monitoring and being started on Heparin, his symptoms resolved very rapidly.

Diagnostics: A CT of the brain indicated a possible ischemic event in the right frontoparietal region and an old lacunar infarct to the basal ganglia on the right. The chest x-ray showed mild congestive heart failure, although this was not clinically apparent. Carotid studies showed minimal abnormalities with approximately 30 percent disease on the left internal carotid. The right side was normal.

An echocardiogram of the heart indicated minor valvular abnormalities of no significance and an ejection fraction of 35 percent to 40 percent, and no embolic clots were noted. A routine cardiogram showed some old findings of left anterior hemiblock.

As mentioned, the patient's symptoms rapidly resolved. He was seen in consultation by Dr. G. the following morning who felt that he did not need IV heparin for the current event and that aspirin should be sufficient. Some consideration was given that if he had future episodes, of starting either Plavix or possible long-term Coumadin. Arrangements were made for discharge, as the patient's basic clinical status has returned to baseline.

Discharge Medications

Glucophage 500 mg b.i.d.

Glyburide 5 mg b.i.d.

Lipitor 20 mg daily

Ecotrin 325 mg daily

Discharge Instructions

Diet—ADA diet, low fat. He was advised at length about smoking cessation. Activity—As tolerated, but no heavy exertion. It was suggested that at some point the patient have an MRI and an MRA as an outpatient and consideration be given to stronger anticoagulation if he has further episodes. Follow-up in the office in approximately one to two weeks.

Emergency Department

History of Present Illness: This is a 62-year-old male who complains of five days of dizziness and three days of weakness, decreasing ambulation, and unsteadiness. He complains of no pain or numbness of the lower extremities, chest pain, fever, or headache. He does complain of having mild vision blurring with turning when he turns his head. The patient has also had slurring of his speech. He was seen yesterday by his private physician who noticed his ataxia and has him scheduled for a magnetic resonance imaging today.

Past Medical History

1. Diabetes mellitus

2. Myocardial infarction times three in the past

3. Coronary artery bypass graft done in the past five years

4. Hypertension

5. History of lacunar infarction with no residuals

Social History: The patient lives in a private home by himself. He smokes two packs of cigarettes a day. He denies any drinking.

Medications

1. Glucophage

2. Talacen

Allergies: No known allergies.

Review of Systems: Negative except for the pertinent positives and negatives noted in the history of present illness.

Physical Examination

Vital Signs: Temperature is 97. Pulse of 84. Respirations 20. Blood pressure 132/73. General: The patient is mildly sleepy but very alert and cooperative with the examination. HEENT: He is normocephalic. Atraumatic. He has some mild preauricular swelling on the right as compared to the left. His tympanic membranes were normal bilaterally. Extraocular muscles intact. Pupils equal, round, reactive to light and accommodation. Oral pharynx is normal. He did have some staining consistent with tobacco.

Neck: Supple. No adenopathy.

Heart: Regular rate and rhythm without any murmurs, thrills, or rubs. He has 21 pulses radial and brachial bilaterally.

Lungs: Breath sounds are clear bilaterally with no tachypnea or retraction.

Abdomen: Mildly tender at the left upper quadrant over the rib area. Otherwise the abdomen was soft and nondistended.

Extremities: He had upper and lower extremity strength of 15.

Neurology: There is 212 and grossly intact. He had no pitting edema or other lesions noted. The patient was ataxic.

Laboratory and Diagnostics: Labs were obtained. Basic metabolic profile showed a sodium of 138, potassium 4.0, chloride of 107, bicarbonate of 22, glucose of 106, blood urea nitrogen of 21, and creatinine of 0.8. Calcium is 9.4. PT and partial prothrombin time were 13.2 and 29.8. White blood cell count was 11.4. H&H is 15.4 and 45.7. He had 222,000 platelets, 62 segs, 29 lymphs, 4 monocytes, 3 eosinopllils, and no basophils. CT scan of the head showed a new infarction of the brain and old lacunar infarct.

Emergency Department Course: We talked to the primary care physician who agreed with the admission of this patient.

Plan: The patient was admitted to a monitored bed. Assisting physician helped coordinate the care, management, and treatment of this patient with myself. The patient is being admitted to the primary care physician's service.

Neurologic Consultation

History: This is a 62-year-old white male whom we were asked to evaluate regarding dizziness and a possible new stroke.

The patient's neurologic history recently appears to date back to approximately one month ago when he developed what he described as some double vision. He was seeing things side by side. He did see his primary care physician who felt this may have been due to a diabetic extraocular movement palsy, and the patient was given a patch. After three weeks, his symptoms resolved. Around that same time, about a month ago, he noticed some numbness and tingling in his fingertips which at times is still bothersome. He was doing fine until this past Saturday when he had the onset of what sounds like dysequilibrium or vertigo where he had difficulty walking. This was transient and then seemed to resolve. This is not currently a problem for him now, and he is much better. The patient tells me that his son told him he may have had some slurred speech, but he is not aware of it. He reported no other specific symptoms. Specifically, he reported no headache. He denies any new change in his vision in the last week. He reported no other areas of focal numbness or tingling. He reported no trouble with focal weakness. He felt like his balance was only off for a short period of time but then resolved. His bowel and bladder function had been fine. He has had no nausea or vomiting. He denies any chest pain, palpitations, or shortness of breath. He did see his primary care physician who told him that some of his problems may have been related to recent medication change and felt that otherwise he would be okay. However, when seeing the physician the day of admission, he was noted to be somewhat ataxic and was admitted to rule out a new stroke.

Laboratory Data: Current blood work on admission showed normal electrolytes. Digoxin level was less than 0.3. CPK levels have been normal. White count was 11.4 with the remainder of his CBC normal. INR was normal at 1.3. He has remained neurologically stable since admission.

Diagnostics: MRI and MRA are pending. Echocardiogram was grossly suboptimal with an ejection fraction of 35 percent to 40 percent. Carotid ultrasound preliminarily showed no stenosis. Heparin is on hold at this time pending our evaluation and the results of the MRI and MRA.

Current Medications

1. Glucophage

2. Insulin coverage

3. Lasix

4. DiaBeta

5. Lipitor

Neurologic Examination: On exam, the patient is awake and alert. He is fully oriented. He is able to name and repeat. Attention, concentration, and memory are okay. Cranial nerves II-XII are grossly intact. Neck is supple with no bruits. Motor exam appears symmetric with no significant focal weakness. He has fairly good bulk and tone. There is no tremor. Sensory exam is remarkable for stocking glove sensory loss. Reflexes are symmetric and somewhat diminished in the lower extremities. Gait is only minimally wide based and he is able to ambulate on his own without any clear ataxia noted at this time. Coordination testing is symmetric. Romberg is negative. He does have difficulty with heel-to-toe walk.

Impression: The patient presents now with transient vertigo along with some slurred speech. This combined with the recent history of double vision certainly warrants a workup for vertebrobasilar insufficiency.

Recommendations:

Echocardiogram as done

Carotid ultrasound as done

MRI and MRA as done

If MRI and MRA are negative, along with the other studies, then treatment with antiplatelet therapy is certainly reasonable.

Physical therapy

Blood pressure and blood sugar control while avoiding relative hypotension

We will likely need to stop heparin or discontinue its use even while being held, as long as studies appear normal. If all of this is okay, and the patient is stable on his feet, discharge then could be shortly.

 

Code Assignment Including POA Indicator

ICD-10-CM Principal Diagnosis:

ICD-10-CM Additional Diagnoses:

Answer & Explanation

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