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Directions: The purpose of this assignment is for you to exhibit your critical thinking skills by coding the medical chart. You are also required to complete the assignment by using the 3M encoder. Provide a screenshot from 3M of your work for questions 1 and 5. Your professor will evaluate your answers for coding guideline usage, communication from individual perspective, coding abstraction, sequencing and 3M encoder usage. Please provide all answers in the appropriate boxes listed below the questions. What is the principal diagnosis? What pathway did you take in order to code the condition properly? Please provide a screen shot of encoder usage for your answer ADMISSION DATE: 04/26/YYYY DISCHARGE DATE: 04/30/YYYY ADMISSION DIAGNOSIS: Fever of undetermined origin. DISCHARGE DIAGNOSIS: Acute pyelonephritis. SUMMARY: This 30 year old white female had high fever off and on for several days prior to admission without any localizing signs or symptoms. Preliminary studies done as an outpatient were unremarkable except to indicate an infection some place. She was ultimately seen in the office, temperature was 103 to 104. She was becoming dehydrated, washed out, weak, tired, and she was admitted for further workup and evaluation. Workup included a chest x-ray that was normal. Intravenous pyelogram was normal. Blood culture report is normal. Urine culture grew out Escherichia coli greater than 100,000 colonies. Throat culture was normal. One blood culture did finally grow out an alpha strep viridans. I talked to Dr. Burke about this and we decided on the basis of her clinical condition and the fact that this did not grow on all bottles it was more likely a contaminate. Urine showed a specific gravity of 1.010, albumin 1+, sugar and acetone were negative, white blood cells 6 to 8, red blood cells 1 to 2. White count 13,100, Hemoglobin 12, hematocrit 35.1, segmental cells 81, lymphocytes 11, monocytes 5, eosinophils 1, bands 2. Mononucleosis test was negative. Alkaline phosphatase 127, blood sugar 125, sodium 142, potassium 4.7, carbon dioxide 30, chloride 104, cholesterol 119, Serum glutamic oxaloacetic transaminase 41, lactate dehydrogenase 151, creatinine 0.9, calcium 9.8, phosphorus 3.3, bilirubin 0.6, total protein 6.8, albumin 4.0, uric acid 6.5. Electrocardiogram was reported as normal. She was started on intravenous fluids, intravenous Keflex, her temperature remained elevated for approximately 48 hours and now has been normal for the last 48 to 72 hours. She feels better, hydration is better, eating better, no urinary symptoms. She’s being discharged at this time on Keflex 500 four times per day, increased fluid intake. To be seen in follow up in the office in 1 week.
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