HIT 208 |documentation is from the health record of a 34-year-old male

7.22. The following documentation is from the health record of a 34-year-old male. Discharge Summary History of Present Illness: The patient is a 34-year-old male who was transferred to the hospital with the diagnosis of rule out AIDS. The patient dates the onset of his current illness to two months prior to admission when he had a tooth extraction. The patient does not know whether he was treated with antibiotics at that time; however, he does note that the socket was packed. The patient states after the above tooth extraction, he developed a fever with shaking chills, night sweats, and anorexia. He had a weight loss of about 12 pounds. He also reported the onset of mild right flank pain associated with foam in urine and urinary frequency. There was no hematuria, dysuria, incontinence, urinary retention, hesitancy, or slow stream. The patient complains of occasional diarrhea but no melena or bright red blood per rectum. Medications on transfer are Codeine, Lasix, Amphojel, Mylanta, Penicillin, Ranitidine, Halcion. Social history is remarkable for continuous IV drug abuse, both heroin and cocaine. There is no history of homosexual activity. He does not drink alcohol but smokes a half-pack of cigarettes a day. Pertinent Lab, X-Ray, and Consult Findings: This patient is a 34-year-old, well-developed, well-nourished male in no acute distress. Mucous membranes are moist. There is a questionable white area at the outer aspect of the right lower gingiva near second tricuspid. There are small mobile submandibular and posterior cervical nodes. The patient also has bilateral inguinal adenopathy and two left epitrochlear nodes. Chest x-ray showed minimal blunting of both costophrenic angles, no definite effusions are noted. There are confluent patches of infiltration in the left midlung field spanning from the hilum to the periphery as well as in the right lower lung. These findings are nonspecific, but could very well fit in with the diagnosis of Pneumocystis carinii pneumonia. Urinalysis negative. CBC: Hemoglobin 9.0, hematocrit 27.2, MCV 87, WBC 5.1, 11 lymphs, S monos, platelets 206,000. Sodium 130, potassium 3.98, chloride 112, CO2 10, BUN 50, creatinine 4.7, glucose 82, calcium 7.0, albumin 0.80. Sputum culture showed normal respiratory flora with normal Enterobacter aerogenes. Urine culture showed no growth. Hospital Course by Problem List Problem #1. Acquired immunodeficiency syndrome: The patient's history was significant for weight loss. Social history significant for IV drug abuse. Physical examination revealed diffuse lymphadenopathy. Laboratory data revealed neutropenia with lymphopenia. Serological test was positive for HIV. Problem #2. Pneumocystic carinii pneumonia: The patient underwent bronchoscopy and biopsy from the left and right lower lobes revealed changes consistent with pneumocystic carinii. The patient was treated with two weeks of intravenous Septra therapy. However, there was no improvement in his clinical status. After two weeks of therapy, the patient was still afebrile. His chest x-ray did not improve and WBC count progressively declined to a low of 2.5. The infectious disease service recommended Pentamidine therapy at that point. The patient became afebrile. Problem #3. Chronic renal failure: The patient's renal failure deteriorated during his hospitalization prior to transfer. Workup was negative and the etiology remains unclear. The patient's renal function remained stable throughout this hospitalization. At the time of transfer, his BUN and creatinine were 50 and 5.0, respectively. He was started on Bicitra therapy to correct the metabolic acidosis felt secondary to his renal failure. Problem #4. Nephrotic syndrome secondary to renal failure: The patient was found to have edema, hypoalbuminemia, proteinuria, and high triglyceride levels, all consistent with the diagnosis of nephrotic syndrome. The patient did have a renal biopsy done prior to transfer to this hospital and the results per phone report are as follows: Interstitial nephritis, no deposits over capillary loops, no immunofluorescence of CMV. The patient was treated with bed rest, a low-sodium, high-protein fluid restriction diet. In spite of this therapy, the patient's albumin level had not improved at the time of transfer. Problem #5. Chronic iron deficiency anemia secondary to blood loss from external hemorrhoid bleeding. The patient required transfusion of two units of packed red blood cells via a peripheral vein. Otherwise, his hematocrit remained relatively stable throughout the admission. Physical examination revealed swollen hemorrhoids with stool heme negative. The patient was transferred in stable condition to the local hospital. Medications at the time of transfer were Bicitra, Pentamidine, Restoril, Lorazepam. Which of the following is the correct code assignment for this admission? a. B20, B59, E87.2. N12, N18.9, D50.0, F14.10, F11.10, K64.4, F17.210, 0BB68ZX, 0BBB8ZX, 30233N1 b. B20, B59, E87.2, N12, N18.9, D50.0, K64.4, F17.210, 0BB68ZX, 0BBB8ZX, 30233N1, 30233N1 c. B20, B59, N12, N18.9, D50.0, F14.10, F11.10, F17.210, 0BB68ZX, 0BBB8ZX, 30233N1 d. B59, B20, N12, N18.9, D50.0, F14.10, F11.10, F17.210, 0BB68ZX, 0BBB8ZX, 30233N1 7.24. History The patient is a 78-year-old female who was initially admitted to the intensive care unit for sepsis and urinary tract infection and decreased level of consciousness. After admission to the intensive care unit, the patient was found to have a massive right-sided cerebrovascular accident, which was felt to be secondary to an embolic phenomenon. CT of the head revealed an acute left middle cerebral arterial infarction involving the temporal and parietal lobes with localized mass effect and mild midline shift. No hemorrhage was seen. The patient's sepsis was treated with IV antibiotics as was her urinary tract infection. Discussion was undertaken with the patient's next of kin as to the patient's resuscitation status. The patient was made a Do Not Resuscitate. Decision was made to keep the patient comfortable, and she was transferred to a medical bed. The patient's antibiotics were adjusted by an infectious disease group. Her acute renal failure which was determined to be due to her severe sepsis was followed by nephrology. Neurology was consulted for the patient's cerebrovascular accident. They did an EEG, which showed marked slowing; however, there was no total absence of brain activity. Cardiology consultation was obtained because of new onset atrial fibrillation. Cardiology felt that no aggressive intervention was needed; however, she would be given medicine to control her ventricular rate. The patient remained unresponsive. She was started on tube feeding and her antibiotics were continued. The patient was noted to have some thrombocytopenia as well as her continued acute renal failure and anemia. Diuresis was attempted with IV diuretics by nephrology in an attempt to help the patient's congestive heart failure. The patient was retaining copious amounts of fluid despite the diuretics. Her prothrombin time eventually normalized. Her blood sugar was elevated, and she was placed on insulin once per day at bedtime to cover her tube feedings. The patient was found without audible or visible respirations and no heart tones. She was pronounced dead at 12:40, and her body was released to the funeral home. Which of the following code sets would be assigned by the hospital for this admission? a. A41.9, R65.20, N39.0, N17.9, I63.412, I50.9, I48.91, D69.6, D64.9 b. R65.20, A41.9, N39.0, N17.9, I63.412, I50.9, I48.91, D69.6, D64.9, Z66 c. A41.9, R65.20, N39.0, N17.9, I63.412, I50.9, I48.91, D69.6, D64.9, Z66 d. I63.412, A41.9, R65.20, N17.9, I50.9, I48.91, D69.6, D64.9, Z66 7.26. In the following case scenario, a 26-year-old white male was admitted after being transferred from the outpatient evaluation service with severe homicidal and suicidal ideation. Admitting diagnosis was severe major depressive disorder with psychotic features. The patient uses cannabis weekly. Pharmacologic treatment was initiated and suicide precautions were instituted. After a thorough neuropsychological, personality, and behavioral psychologic evaluation, the risks and benefits of ECT were reviewed. Due to the severity of the psychotic episode and the patient's delusional state, it was determined that ECT was warranted. Extensive efforts were made to secure informed consent from the patient, and a course of single seizure unilateral ECT was begun. ECT was administered three times per week, and the course of therapy was completed in a three-week period. On the fourth treatment of ECT, postictal observation was notable for cardiac arrhythmia, which subsided without sequelae. Otherwise, the patient tolerated the therapy well and responded quickly with resolution of the psychotic features and overall improvement in the acute phase of his depressive disorder. Suicide precautions could be lifted after the fifth treatment with ECT. After establishing adequate therapeutic levels of lithium, the patient was discharged to be managed as an outpatient. Discharge Diagnosis: Severe major depressive disorder with suicidal ideation, stabilized after a course of ECT. Which is the correct code set for reporting this case scenario? a. F32.3, R45.851, R45.850, F12.90, GZB0ZZZ, GZ3ZZZZ, GZ11ZZZ, GZ13ZZZ b. F32.2, R45.851, R45.850, GZB0ZZZ, GZ3ZZZZ, GZ11ZZZ, GZ13ZZZ c. F32.3, GZB0ZZZ d. F32.2, R45.851, R45.850, F12.20, GZB0ZZZ