7.47. Discharge Summary
Date of Admission: 2/3
Date of Discharge: 2/5
Discharge Diagnosis: Full-term pregnancy-delivered male infant
Patient started labor spontaneously three days before her due date. She was brought to the hospital by automobile. Labor progressed for a while but then contractions became fewer and she delivered soon after. A midline episiotomy was done. Membranes and placenta were complete. There was some bleeding but not excessive. Patient made an uneventful recovery.
History and Physical
Reason for Admission: Full-term pregnancy
Past Medical History: Previous deliveries normal and mitral valve prolapse
Allergies: None known
Chronic Medications: None
Family History: Heart disease-father
Social History: The patient is married and has one other child living with her
Review of Systems
Heart: Slight midsystolic click with late systolic murmur IIIVI
Impression: Good health with term pregnancy. History of mitral valve prolapseasymptomatic
2/3: Admit to Labor and Delivery. MVP stable. Patient progressing well.
Delivered at 1:15 p.m. one full-term male infant.
2/4: Patient doing well. MVP prolapse stable. The perineum is clean and dry, incision intact.
2/5: Will discharge to home.
The patient was 3 em dilated when admitted. The duration of the first stage of labor was 6 hours, second stage was 14 minutes, third stage was 5 minutes. She was given local anesthesia. An episiotomy was performed with repair. There were no lacerations. The cord was wrapped once around the baby’s neck, but did not cause compression. The mother and liveborn baby were discharged from the delivery room in good condition.
Are these codes correct? If not, make them correct. 663.31, 648.61, 424.0, 73.6
7.50/7.51. The following documentation is from the health record of a 67-year-old female patient.
Brief History: This 67-year-old female was transferred here for further evaluation of continued respiratory failure. She has a long history of asthma and chronic obstructive pulmonary disease. Current medications: Claforan 1 gram q. 6 h., Cardizem SR 90 mg b.i.d., Solu-Medrol125 mg intravenously q. 8 h., Trentall p.o. b.i.d., DiaBeta 1.25 mg p.o. q. a.m. and 2.5 mg q. p.m., Klonopin 1 mg p.o. q. 6 h., Ibuprofen 800 mg p.o. b.i.d., Lortab 5 mg q. 6 h. p.r.n. headache, Atrovent and Proventil inhalers at bedside.
Physical Examination: She was intubated. Admission ABGs were P02 40, PC02 55, and pH 7.30. Blood pressure 156/89, heart rate 130 beats per minute, temperature 100.7°F. Neck: No jugular venous distention. Carotid normal upstroke without audible bruits. Pulmonary exam: Decreased breath sounds throughout. Expiratory wheezes were auscultated. Cardiac exam: Sinus tachycardiac rhythm. No murmurs or gallops. Extremities: No edema.
Hospital Course: Upon admission, emergent pulmonary consultation was obtained, and a fiberoptic bronchoscopy was performed without difficulty. Copious, thin white pus was noted in all of her inflamed airways. She had no cough despite airway suctioning. A #7.5 nasotracheal tube was inserted via her right naris without difficulty, and airways were aspirated clear. The patient was placed on Ventolin 2 mg p.o. q 6 h., placed on Proventil inhaler 1 mg q. 4 h. and q. 2 h. p.r.n., placed on oxygen, and was given intravenous Lasix and intravenous Solu-Medrol. A Dobbhoff NG tube was placed the day after admission without difficulty. Two days later, she developed a temperature of 103°F and developed chills. All cultures obtained on admission revealed no growth thus far, and a chest x-ray was clear.
Infectious disease consultation was obtained, and a workup was ordered to rule out sinusitis, viral upper respiratory tract infection, drug fever, collagen vascular disease, or occult abdominal source. Antibiotic coverage in the form of Unasyn and tobramycin ordered along with yeast coverage. Other problems included hypokalemia, which required potassium repletion, frequent premature atrial contractions, and marked metabolic alkalosis preventing weaning from her intubation. The only source of fever seemed to be the maxillary and ethmoidal sinusitis on the CT scan, and her head was elevated to decrease venous congestion of the sinuses.
GI consultation was obtained when she started developing abdominal distention and coffee-ground emesis; hematocrit level had dropped from 37.8 to 24.2 for which she was given two units of packed red blood cells. The consultant felt that a GI bleed could possibly be related to stress, nonsteroidal anti-inflammatory drugs, or gastritis, and that the abdominal distention was probably aerophagia related to the ventilator. The recommendation was made to stop the tube feedings and decompression with nasogastric tube and checking stools for hemoccult. Gallbladder ultrasound revealed gallstones in the thick walls of the ducts.
The patient continued to have abdominal pain. Surgical consultation was ordered and confirmed acute cholecystitis, which could be worse secondary to the steroids. The day of consultation, the patient underwent exploratory laparotomy, bilateral salpingo-oophorectomy, cholecystectomy, cholangiogram, and omental biopsy. Cystadenofibroma of borderline malignancy of the right ovary was reported on pathological findings.
The patient developed anasarca and required intravenous diuretics. She underwent another fiberoptic bronchoscopy six days postop, which revealed diffused edema and slight inflammation with yellow plugs in the left upper lobe and right middle lobe, and scant secretions otherwise clear and foamy. She also underwent tube feedings with hyper Osmolite. Seven days later, she started developing increasing respiratory distress and a tracheostomy was performed. Tracheal aspirate revealed gram-negative herpetic tracheobronchitis. Within 48 hours, she developed bradycardia and increasing ventilation pressures. Emergency tap of the right pleural space was done, which revealed tension pneumothorax. A trocar chest tube was inserted with good air return. Attempts to see airways via left nares with fiberoptic bronchoscopy revealed all mucosa to be obstructed at the level of the retropharynx. A retap of the left chest revealed air not under pressure, opened with scissors, but still unable to ventilate by tracheal tube. Heart rate was zero, and blood pressure was zero. The futility of cardiopulmonary resuscitation for further events, based on inability to ventilate, led to cessation of efforts and the patient was pronounced dead at 11: 15 a.m.
Final Diagnoses: Acute respiratory failure
Long history of asthma
Chronic obstructive pulmonary disease
Metabolic alkalosis with ventilator dependence for the last week or more of her hospitalization
Gram-negative herpetic tracheobronchitis
Acute cholecystitis and cholelithiasis
Anemia due to GI bleed from undetermined cause
Maxillary and ethmoidal sinusitis
Premature atrial contractions
Cystadenofibroma right ovary
Procedures: Intubation, mechanical ventilation
Fiberoptic bronchoscopy x 3
Cholecystectomy with cholangiogram
Thoracentesis and chest tube
Are these codes correct? 428.83, 518.81, 427.5, 117.5, 261, 33.28, 96.70, 96.01, 33.24, 03.31
7.52. Discharge Summary
Date of Admission: 1/31
Date of Discharge: 2/3
Discharge Diagnosis: Right lower lobe pneumonia due to gram-negative bacteria, resistant to erythromycin
Admission History: This is a 56-year-old insulin-requiring diabetic female whose diabetes is out of control whom we have been following for hypertension, degenerative joint disease, aortic stenosis, and diabetic retinopathy. Over the past three days she has noted increased cough and chest congestion with a fever of approximately 102 degrees. She was found to have a right lower lobe infiltrate and was started on therapy with erythromycin. Despite initial therapy, the patient’s clinical status has worsened over the past 24 hours.
Course in Hospital: Patient was admitted with the diagnosis of right lower lobe pneumonia. She was begun on intravenous ceftriaxone. Because of difficulties with venous access, patient was switched to intramuscular ceftriaxone on her third hospital day.
By 2/3 the patient was afebrile and her cough had diminished. Her blood pressure was well controlled at 140174.
Instructions on Discharge: Follow up with me by phone in three days and in my office in two weeks. Repeat chest x-ray to be done then.
1. Calan SR 180 mg b.i.d.
2. Zestril20 mg PO q. a.m.
3. NPH Insulin, 30 units, sub q., a.m.
4. Levoquin 500 mg PO daily x 10 days
5. Celebrex 100 mg PO b.i.d.
History and Physical
Reason for Admission: Physical examination on admission revealed a well-developed, acutely ill appearing black female.
History of Present Illness: A 56-year-old diabetic followed for hypertension and diabetic retinopathy. Over the past three days she has noted increased cough and chest congestion with a fever of approximately 102 degrees. She was found to have a right lower lobe infiltrate and was begun on therapy with erythromycin. Despite initial therapy, the patient’s clinical status worsened over the past 24 hours and hospitalization was recommended.
Past Medical History: Hypertension, degenerative joint disease in both knees, and moderate aortic stenosis
Chronic Medications: CalanSR 180 mg PO b.i.d., Insulin (NPH), Zestri120 mg PO daily, Celebrex 100 mg PO b.i.d.
Family History: Notable for hypertension in mother
Social History: Noncontributory
General Appearance: The patient is a well-developed black female in moderate distress.
Vital Signs: T 102, P 80, R 16, BP 150/80
Skin: Warm and dry
HEENT: Significant for mildly inflamed mucous membranes. Retinopathy evident in both eyes.
Neck: Supple. Symmetrical with no bruits.
Lungs: Coarse rhonchi bilaterally, right greater than left
Heart: Regular rate and rhythm, positive S1, positive III/VI SEM
Abdomen: Soft, nontender, no mass
Extremities: No edema
1. EKG: NSR, widespread ST-T wave abnormalities, LV hypertrophy
2. CBC: Hgb 13, Hct 38, WBC 12.8
3. Glucose: 281
4. Urinalysis: Unremarkable
5. Sputum: Gram stain-a few WBCs, moderate gram-negative rods
1. Right lower lobe pneumonia possibly due to gram-negative bacteria
2. Diabetes mellitus on insulin-Uncontrolled
4. Degenerative joint disease-Stable
5. Moderate aortic stenosis
Plan: Admit, IV antibiotics for pneumonia. Monitor blood sugars.
1/31 Patient admitted for cough associated with increased temperature with chest x-ray indicative of pneumonia. Will obtain sputum culture and begin on ceftriaxone. Will monitor blood pressure and blood sugars. Will use sliding scale to bring blood sugar into control. Patient with recent echocardiogram as outpatient that showed stable aortic stenosis.
2/1 The patient is responding well. Will request diabetic education nurse to meet with her and set up an appointment for classes following this admission.
2/2 Sputum culture reveals gram-negative bacteria as suspected. Patient’s temperature is down. Patient resting comfortably. Blood sugar better.
2/3 Blood sugar with increasing control today. The importance of appropriate diet emphasized. Will discharge with p.o. antibiotics.
Are these codes correct? 482.83, 250.50, 362.01, V09.2, 715.36, 424.1, V58.67
The post Patient started labor spontaneously three days before her due date. She was brought to the hospital by automobile. Labor progressed for a while but then contractions became fewer and she delivered soon after. A midline episiotomy was done. Membranes and placenta were complete. There was some bleeding but not excessive. Patient made an uneventful recovery. appeared first on commompapers.org.