How to Answer Case Patient Maria Questions (Complete Guide)
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Original Question
Case 3- Patient Maria Redman, 46-year old female Date of Admission: 09/01/YY Date of Discharge: 09/14/YY Admission Diagnosis: Shortness of breath, quadriplegia Discharge Diagnosis: Bilateral pneumonia, dehydration, quadriplegia, atonic bladder, hypokalemia and tobacco dependence. Disposition: The patient is being discharged to home. Her daughter stays with her full-time to care for her. She is to come to the office in one week to get a repeat chest x-ray and then further treatment with her pending results. Hospital Course: The patient is a 46-year-old female who is a quadriplegic after a motor vehicle accident. She had a fever two days prior to admission, so we called her in a prescription for Keflex. She did not improve on this medication, and she came to the emergency room on the day of admission complaining of shortness of breath and cough. She reported a two-day history of shortness of breath, fever, and cough productive of green and yellow sputum. A chest x-ray in the ER showed bilateral lower lobe infiltrates. She was admitted to the hospital for intravenous antibiotics for her pneumonia. The patient was also dehydrated and required IV fluids upon admission to treat this condition. Her temperature per the ER documentation was 102.6 F. After admission to the hospital, the patient was placed on Biaxin, and she did become afebrile. The patient felt better and was discharged to home into the care of her daughter. Work-up during this admission included a glucose of 81, a BUN of 6, a creatinine of 0.5. Electrolytes were normal. Her arterial blood gases show a pH of 7.482, a pCO2 of 33, a pO2 low at 50, HCO3 324, and total CO2 was 55. Her O2 saturation was only 88 percent on room air. She was started on handheld nebulizer treatments, and she rapidly improved. Consult during admission was ordered for smoking cessation, the patient currently smokes 2 packs of cigarettes per day and has done that for 30 years. The smoking is not helping her respiratory status. The work-up during admission, in addition to that above, included serum electrolytes, which were normal except for a potassium level of 3.3. This was corrected with additional potassium. Her hemoglobin level on admission was 13. 5. Hematocrit was 40.1, RBC was 4.40. Her MCV was 9a. Her MCH was 33.5. RDW as 12.7. A urinalysis showed a moderate amount of hemoglobin but no red blood cells. Repeated urinalysis was done to review the status of the patient’s atonic bladder. Her chest x-ray did show a definite infiltrate in her left lower lobe. There is a q question that possible her quadriplegia may affect her ability to breath, necessitating her seeing us for respiratory infections. Also, during this stay she had in room PT to aid in reducing her muscle atrophy due to her quadriplegia. Codes Assigned: Principal DX: R06.02 Additional Diagnoses Codes: J18.0, G82.80, N31.2 Do you agree with the assigned ICD-10-CM codes? If not, what ICD-10-CM codes would you assign? No ICD-10-PCS codes were assigned, do you agree with this? If so, why? If not, why? Do you have any concerns/issues for a physician query? This is the end of the assignment. Review your answers to the posed question before finalizing and submitting your work. Answers are only submitted in the lesson assignment area of the Canvas course.
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