Patient Data Codes Explained for Students (Easy Guide)

This question focuses on applying theory to practical scenarios.

What This Question Is About

This question relates to patient data codes and requires a structured academic response.

How to Approach This Question

Focus on explaining concepts clearly and supporting them with examples.

Key Explanation

This topic involves patient data codes. A strong answer should include explanation, application, and examples.

Original Question

Patient data or codes Notes or comments (if applicable) Patient Name : Virginia Armberg MRN Facility Type Service Location Days or Units Principal Diagnosis Code Secondary Diagnosis Code(s) (list all applicable) Principal Procedure Code Principal Procedure Date Principal Procedure Provider Secondary Procedure Code(s) (list all applicable) MS DRG Code ADMITTING DIAGNOSIS: Fatigue, cough, fever and weight loss. Possible tuberculosis. DIAGNOSIS AT DISCHARGE: Tuberculosis. HISTORY OF PRESENT ILLNESS: Patient presented to the clinic one week ago with complaint of fatigue, productive cough, fever and weight loss. Patient reports her cough has gotten progressively worse over the last several weeks since arriving back home after trip to Asia with church. Vital signs in the office one week ago were as follows: Temp= 102.6F; R= 18; P= 82; BP=114/72. Weight = 130lb. A sputum specimen was collected at the clinic and sent for AFB smear and culture. Patient was given another sputum container to take home with instructions to obtain an early morning sputum specimen the next day and to return to the clinic. She returned the following day with the sputum specimen she collected at home and a third sputum specimen was collected on the in the clinic. Several days later, the sputum smears results are reported as follows: Negative, Positive, Positive. PHYSICAL ASSESSMENT PRIOR DISCHARGE: GEN: Well developed, well nourished, pleasant Caucasian woman in mild respiratory distress, with an occasional cough producing a thin off white tinged sputum. HEENT: NC/AT, PERRL, EOMI, the oropharynx was clear with no lesions, the neck was supple, no lymphadenopathy, no JVD, no bruits, the trachea was midline, there was a normal carotid upstroke. HEART: Regular rhythm, no murmurs, rubs, or gallops. Normal S1 and S2. The PMI was not displaced. No heave. LUNGS: Bilateral diffuse crackles, no wheeze, no dullness to percussion. ABDOMEN: Soft, nontender, nondistended, bowel sounds were normal. There was no hepatosplenomegaly. No rebound or guarding. EXT: No clubbing, no lower extremity edema or swelling, no palpable cords. Negative Homans’ sign. NEURO: The patient was alert and oriented times three. Cranial nerves 2-12 were intact. The DTRs were 2+ bilaterally and symmetric. Sensation within normal limits, weakness improved with hydration and eating. The cerebellar exam was within normal limits. LYMPH: No cervical, axillary, or inguinal lymph nodes were present. SKIN: Warm, dry skin. No rashes, no tattoos. MUSCULOSKELETAL: No synovitis. There were no joint deformities. Full range of motion bilaterally throughout. STUDIES: CXR: Demonstrated bilateral apical fibrosis and left lower lobe consolidation with early cavity formation, consistent with tuberculosis. The cardiac silhouette and pulmonary vasculature were within normal limits. The osseous structures were normal. LABS: PPD positive at 70 hours – 15mm induration Lab drawn this morning: GLUCOSE 95 UREA NITROGEN 20 CREATININE 1.3 BILIRUBIN 1.1 H SODIUM 136 POTASSIUM 4.4 CHLORIDE 100 CO2 31 CALCIUM 9.5 ALBUMIN 3.9 L AST 42 ALT 50 ALP 100 WBC 6.1 RBC 5.1 HGB 13.3 HCT 33 MCH 30.0 MCHC 33 PLT 270 HOSPITAL COURSE: Patient has acquired tuberculosis from her recent trip oversees. During her hospital stay she received IV fluids for hydration and was able to advance from a clear liquid diet to a regular diet. Even though her appetite is not up to normal, she is able to eat with no complaints of n/v. Her temp remains in the 90s and her oxygen saturation is in the low 90s. Her cough has improved slightly. She has been on the TB medications for 3 days now and is tolerating them well. While in the hospital she had a chest x-ray and repeat labs drawn this morning. MRSA swab came back negative. CONDITION OF PATIENT UPON DISCHARGE: Stable DISCHARGE DISPOSITION: Discharge home this morning. A friend is coming to give her a ride home and will stay with her until her daughter arrives this evening. Continue patient on multi-drug treatment (isoniazid, rifampin, ethambutol). Clinic Pharmacy is delivering to patient’s home today. ABD Home health to evaluate and assist with care and education as needed for 1 week. Evaluation this afternoon. County Health Department to evaluate and follow during course of treatment. Initial visit this afternoon. Home health and health dept nurses to provide education on her personal care at home, when she leaves her home, protecting herself and others, full TB education and reinforcement with every visit. Call the clinic office or go to the ER for any changes: temp greater than 101 that is not coming down with acetaminophen, decreased appetite, weight loss of greater than 3 lbs, increase in cough or sputum production, shortness of breath, nausea and vomiting not controlled by ondansetron. Activity as tolerated. Diet as tolerated. Drink plenty of fluids. MEDICATIONS: Isoniazid 100mg PO four times a day Rifampin 300mg PO four times a day Ethambutol 100mg PO four times a day Acetaminophen 1000mg PO every 4-6 as need for temperature greater than 101 degrees F or mild discomfort. Ondansetron 4mg SL every 8 hours PRN for nausea/vomiting FOLLOW UP: See in my office in 2 weeks for follow up visit.

******CLICK ORDER NOW BELOW AND OUR WRITERS WILL WRITE AN ANSWER TO THIS ASSIGNMENT OR ANY OTHER ASSIGNMENT, DISCUSSION, ESSAY, HOMEWORK OR QUESTION YOU MAY HAVE. OUR PAPERS ARE PLAGIARISM FREE*******."