Location Inpatient Hospital Assignment Help: How to Answer This Question
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Original Question
LOCATION: Inpatient, Hospital PATIENT: Ervin Gulman PRIMARY CARE PHYSICIAN: Ronald Green, MD ATTENDING PHYSICIAN: Gregory Dawson, MD The patient was admitted with pneumonia, increasing shortness of breath, and failure to thrive. He had been treated as an outpatient for similar things but has gradually declined and become quite fatigued and increasingly short of breath. He had acute pneumonia, unknown organism, at the time of admission. I do not think our cultures helped much in identifying a causative organism. His case was gradual slow improvement. He was able to take care of himself a little bit, and he was able to be discharged. The Gram stain suggested a streptococcal or even a streptococcal organism with moderate gram-positive cocci in pairs and gram-negative cocci in clusters, but no cultures actually revealed pathogenic diagnosis. We finally were able to discharge him today to his home under the care of his family. MEDICATIONS: he was discharged with were: 1. Albuterol nebulizer four times a day and then q.3h. (every 3 hours) p.r.n. (as needed) 2. BuSpar 10 mg (milligram) q.d. (every day) 3. Vantin 200 mg b.i.d. (twice a day) 4. Atrovent four times a day with the albuterol 5. Theo-Dur 200 mg q.d. 6. Oxygen The Vantin will be discontinued on the 5th after his dose on that day. Follow-up will be in a week in the office to repeat his chest x-ray. His O2 (oxygen) was set at 4 L (liter) with 2 L continuously. DISCHARGE DIAGNOSES: 1. Pneumonia 2. Chronic respiratory failure 3. Chronic obstructive pulmonary disease, O2 dependent SERVICE CODE(S): __________________________________________ ICD-10-CM DX CODE(S): _____________________________________
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