Community-Acquired Pneumonia Chief Complaint "I have been coughing, have chest pain, and cannot breathe for about 2 days now." History of Present Illness MR X 40-year-old male who presents to the emergency department with a fever, cough, chest pain (worsening when breathing or coughing), and shortness of breath. Normally, he has a fairly active lifestyle as he trains for marathons. He has not traveled outside Metro Manila recently. He states he has "been taking cough medicine at night" for the past 4 days to help him sleep, but it has not been getting better. Also, he reports that he has been waking up at night due to heavy sweating. He states all his symptoms have gotten worse in the last 2 days. After being assessed in the ED, MR X is admitted to the medicine unit for further workup. Treatment includes 02 inhalation 3L via nasal prong / min and antibiotics, Levofluxacin 500mg tab OD, PLR 1L to run at KVO rate. Past Medical History Diabetes: Type 1 Surgical History N/A Family History Father has diabetes: Type 1, history of heart attack; mother has hypertension. Social History Married with no kids. Denies smoking and drinks alcohol occasionally (weekends, social events) Allergies NKDA Home Medications Insulin (bolus/basal: -35 units total daily) Aspirin 81 mg PO daily (cardiovascular protection) Atorvastatin 20 mg PO daily (cardiovascular protec Physical Examination Vital Signs Temp 100.8'F, HR 110 bpm, RR 30, BP 125/75 mm Hg, p02 90%, Ht 5'9", Wt 70 kg General Slightly lethargic, mild-moderate distress HEENT Normocephalic, atraumatic, PERRLA, EOMI, normal mucus membranes and conjunctiva, adequate dentition Pulmonary Diminished breath sounds and crackles (rales) bilaterally Cardiovascular NSR, no mirig Abdomen Soft, non-distended, non-tender, bowel sounds hyperactive Neurology Lethargic, oriented to place and person, (-) Brudzinski's sign, (-) Kernig's sign Extremities No significant findings Vaccines States he cannot remember all of them. He says he received all his age- related vaccines when younger . Has not received his flu-shot this year as he always forgets to receive it. Laboratory Findings Na = 148, mEq/L Hgb= 14 g/dl Ca 8.5 mg/dL K= 4.3 mEg/L Hct = 38% Mg = 2.3 mg/dL CL = 115 mEqL Pit = 300 x 1o'/mm Phos =

Community-Acquired Pneumonia Chief Complaint "I have been coughing, have chest pain, and cannot breathe for about 2 days now." History of Present Illness MR X 40-year-old male who presents to the emergency department with a fever, cough, chest pain (worsening when breathing or coughing), and shortness of breath. Normally, he has a fairly active lifestyle as he trains for marathons. He has not traveled outside Metro Manila recently. He states he has "been taking cough medicine at night" for the past 4 days to help him sleep, but it has not been getting better. Also, he reports that he has been waking up at night due to heavy sweating. He states all his symptoms have gotten worse in the last 2 days. After being assessed in the ED, MR X is admitted to the medicine unit for further workup. Treatment includes 02 inhalation 3L via nasal prong / min and antibiotics, Levofluxacin 500mg tab OD, PLR 1L to run at KVO rate. Past Medical History Diabetes: Type 1 Surgical History N/A Family History Father has diabetes: Type 1, history of heart attack; mother has hypertension. Social History Married with no kids. Denies smoking and drinks alcohol occasionally (weekends, social events) Allergies NKDA Home Medications Insulin (bolus/basal: -35 units total daily) Aspirin 81 mg PO daily (cardiovascular protection) Atorvastatin 20 mg PO daily (cardiovascular protec Physical Examination Vital Signs Temp 100.8'F, HR 110 bpm, RR 30, BP 125/75 mm Hg, p02 90%, Ht 5'9", Wt 70 kg General Slightly lethargic, mild-moderate distress HEENT Normocephalic, atraumatic, PERRLA, EOMI, normal mucus membranes and conjunctiva, adequate dentition Pulmonary Diminished breath sounds and crackles (rales) bilaterally Cardiovascular NSR, no mirig Abdomen Soft, non-distended, non-tender, bowel sounds hyperactive Neurology Lethargic, oriented to place and person, (-) Brudzinski's sign, (-) Kernig's sign Extremities No significant findings Vaccines States he cannot remember all of them. He says he received all his age- related vaccines when younger . Has not received his flu-shot this year as he always forgets to receive it. Laboratory Findings Na = 148, mEq/L Hgb= 14 g/dl Ca 8.5 mg/dL K= 4.3 mEg/L Hct = 38% Mg = 2.3 mg/dL CL = 115 mEqL Pit = 300 x 1o'/mm Phos =

Understanding Health Insurance: A Guide to Billing and Reimbursement

14th Edition

ISBN:9781337679480

Author:GREEN

Publisher:GREEN

Chapter6: Icd-10-cm Coding

Section: Chapter Questions

Problem 218R

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