How to Answer Location Inpatient Hospital Questions (Complete Guide)

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Original Question

LOCATION: Inpatient, Hospital PATIENT: Ervin Gulman PRIMARY CARE PHYSICIAN: Ronald Green, MD ATTENDING PHYSICIAN: Gregory Dawson, MD EXAMINATION OF: Chest CLINICAL SYMPTOMS: Pneumonia, COPD (chronic obstructive pulmonary disease), and chronic respiratory failure PA (POSTERIOR/ANTERIOR) AND LATERAL CHEST X-RAY, 9:15 AM: Previous portable upright only yesterday CLINICAL INFORMATION: There is cardiomegaly, as there has been on previous x-rays for this patient. The vascular markings on the left are within normal limits. On the left, there is what appears to be interstitial fibrosis, mid-lung and base. No left effusion suggested. On the right, there is abnormal density throughout the right lung that is interstitial in nature and could be unilateral failure pattern. That is less confluent than it was in the right upper lobe compared with the previous report. The remainder of the right lung (mid-lung and base) shows no change from previous report. There is blunting of the right costophrenic angle and the right posterior sulcus suggesting a small effusion that is stable. There is some pleural density along the right lateral chest wall and over the apex that is assumed to be scarring. There is degenerative change of the thoracic spine, mild. No destructive lesion or fracture is seen. IMPRESSION: 1. Cardiomegaly stable 2. No vascular congestion on the left. The left lung shows scar but no active parenchymal disease and no left effusion. 3. On the right, there is a pleural scar along the right lateral chest wall and over the apex. 4. There is abnormal interstitial finding throughout the entire right lung except for the apex. That is abnormal and is new compared with the previous film, indicating that it is an acute finding. It could be a unilateral failure pattern. It could be interstitial pneumonia. There is slightly improved aeration in the periphery of the right upper lobe compared with the film taken 2 days ago. The remainder of the chest is stable. 5. Suggestion of small effusion on the right. SERVICE CODE(S): ________________________________________ ICD-10-CM DX CODE(S): ____________________________________

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