Like Medical Coder Explained for Students (Easy Guide)
This type of question evaluates analytical and critical thinking skills.
What This Question Is About
This question relates to like medical coder and requires a structured academic response.
How to Approach This Question
Use appropriate theories and support your answer with clear reasoning.
Key Explanation
This topic involves like medical coder. A strong answer should include explanation, application, and examples.
Original Question
act like a medical coder FINAL DIAGNOSES: 1. Left anterior chest pain with cyanosis and tachypnea episodes 2. Probable right lingular pneumonia 3. Alzheimer’s Disease 4. Chronic obstructive pulmonary disease 5. Atrial fibrillation This 80-year-old white male was admitted from the Alzheimer’s unit at St. Ann’s Care Center. He has a history of COPD and presented with increased shortness of breath, tachypnea, and left sided chest pain. Cyanosis was noted by the St. Ann’s staff. He was brought to the ED for evaluation and was diagnosed with possible pneumonitis. He was admitted to Intensive Care to rule out cardiac disease. MEDICATIONS: Remeron 7.5 mg hs ALLERGIES: None. PHYSICAL EXAMINATION: Initial vital signs: T 98.1, P 102 and regular, R 20 and BP 120/69. Unmarkable HEENT exam. No cyanosis noted. Neck supple. No carotid bruits identified. No thyroid enlargement. Chest exam unremarkable except for a rub in the left anterior chest area inferiorly. Cardiovascular exam revealed a normal S1 and S2 with rub present. No heaves or thrills. Regular rhythm was noted. Abdominal examination was unremarkable without organomegaly or masses. Normal bowel sounds. Extremities were negative. No peripheral edema. Excellent peripheral pulses. No ulcerations or areas of skin breakdown were noted. LABS: Initial CBC: hemoglobin 14.5, hematocrit 44.1, MCV mildly decreased at 82.4. WBC: 20,100 with 76 segs 10 bands, 10 lymphs, and 3 monos. Sodium was 141, potassium 4.6, creatinine 1.6, BUN 28 and glucose 153. Alkaline phosphatase was slightly decreased at 50 but otherwise liver functions were normal. Troponin was minimally elevated at 1.2 but CK was normal at 108. Unremarkable UA. EKG showed sinus tachycardia with nonspecific ST-T segment changes. Chest x-ray revealed a prominent epicardial fat pad on the right with a possible infiltrate in the left lingular region. Areas of fibrosis, degenerative disc disease and osteoarthritis changes in the spine were noted. Flat plate and upright x-rays of the abdomen revealed some intra-arterial calcification but no free air or organomegaly. An abdominal ultrasound was done to evaluate the rub and elevated white count. The patient had some possible splenic enlargement but no other noted abnormalities. Patient is status post cholecystectomy What is the principal diagnosis? I48.91 J18.1 F02.80 R07.9
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