ICD-10 Discharge Summary Date of Admission 1/31 Date of Discharge:2.3 Discharge Diagnosis: Right lower lobe pneumonia due
Question:
ICD-10 Discharge Summary
Date of Admission 1/31 Date of Discharge:2.3
Discharge Diagnosis: Right lower lobe pneumonia due togram-negative bacteria, resistant to erythromycin.
Admission History: This is a 56-year-oldinsulin-requiring diabetic female whose diabetes is out of controlwhom we have been following for hypertension, degenerative jointdisease, aortic stenosis and diabetic retinopathy. Over the pastthree days she has noted increased cough and chest congestion witha fever of approximately 102 degrees. She was found to have a rightlower lobe infiltrate and was started on therapy with erythromycin.Despite initial therapy, the patient’s clinical status has worsenedover the past 24 hours.
Course in Hospital: Patient was admitted with thediagnosis of right lower lobe pneumonia. She was begun onintravenous ceftriaxone. Because of difficulties with venousaccess, patient was switched to intramuscular ceftriaxone on herthird hospital day.
By ? the patient was afebrile and her cough haddiminished. Her blood pressure was well controlled at140/74.
Instructions on Discharge: Follow up with me by phone inthree days and in my office in two weeks. Repeat chest x-ray to bedone then.
Medications:
Calan SR 180mg b.i.d.
Zestril 20mg PO q.a.m.
NPH Insulin, 30 units, sub q., a.m.
Levoquin 500mg PO daily x10 days
Celebrex 100 mg PO b.i.d.
History and Physical Examination
Admitted: 1/31
Reason for admission: Physical examination on admissionrevealed a well-developed, acutely ill-appearing blackfemale.
History of present Illness: A 56-year old diabeticfollowed for hypertension and diabetic retinopathy. Over the pastthree days she has noted increased cough and chest congestion witha fever of approximately 102 degrees. She was found to have a rightlower lobe infiltrate and was begun on therapy with erythromycin.Despite initial therapy, the patient’s clinical status worsenedover the past 24 hours and hospitalization wasrecommended.
Past medical history: Hypertension,degenerative joint disease in both knees, and moderate aorticstenosis
Allergies: Dust
Chronic Medications: Calan SR 180mg b.i.d., Insulin(NPH), Zestril 20mg PO daily, Celebrex 100 mg POb.i.d.
Family History: Notable for hypertension inmother
Social History: Noncontributory
Physical Examination:
General Appearance: The patient is awell-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 greaterthan left
Heart: Regular rate and rhythm, positive S1,positive III/VI SEM
Abdomen: Soft, nontender, no mass
Genitalia: Deferred
Rectal: Deferred
Extremities: No edema
Neurologic: Normal
Laboratory Data:
EKG: NSR, widespread ST-T wave abnormalities, LVhypertrophy
CBC: Hgb 13, Hct 38, WBC 12.8
Glucose: 281
Urinalysis: Unremarkable
Sputum: Gram stain - a few WBCs, moderate gram-negativerods
Impression:
Right lower lobe pneumonia possibly due to gram-negativebacteria
Diabetes mellitus on insulin-uncontrolled
Hypertension-stable
Degenerative joint disease-stable
Moderate aortic stenosis
Plan: Admit, IV antibiotics for pneumonia. Monitor bloodsugars.
Progress Note
Date Note
1/31 Patient admitted for cough associated withincreased temperature with chest x-ray indicated of pneumonia. Willobtain sputum culture and begin on ceftriaxone. Will monitor bloodpressure and blood sugars. Will use sliding scale to bring bloodsugar into control. Patient with recent echocardiogram asoutpatient that showed stable aortic stenosis.
2/1 The patient is responding well. Will requestdiabetic education nurse to meet with ehr and set up an appointmentfor classes following this admission.
2/2 Sputum culture reveals gram-negative bacteria assuspected. Patient/s temperature is down. Patient is restingcomfortably. Blood sugar better.
2/ 3 Blood sugar with increasing control today. Theimportance of appropriate diet emphasized. Will discharge with p.o.antibiotics.
Physical Orders
Date Note
1/31 Admit to 3 South
Dx: Pneumonia
Please give ceftriaxone 1 g q 8 hours IV
ADA diet
CBC and SMA
Calan SR 50 mg in a.m. with orange juice
Zestril 2 in a.m.
Celebrex 100 mg po BID
Accu-Chek before meals and before bedtime
Chest x-ray
Sliding scale for insulin as follows:
-Below 120 give 4 units of regular
-120-200 give 6 units of regular insulin
-200-300 five 8 units of regular insulin
-Above 300, call physician
2/1 Change insulin to 40 NPH units sq in a/m/today
Consult diabtic nurse to see patient and set up classesfollowing admission.
2/2 Continue insulin to 40 NPH units sq in a.m.today.
2/2 D/C IV and switch to ceftriaxone 1 g IM q.24hrs
2/3 Discharge to home.
Microbiology
Date Test Type
1/31 Source
Site:
GRAM STAIN RESULTS: Sputum
CULTURE RESULTS: Slight WBCs, Slight Epis
Many gram-negative rods
Sl. gram-negative diplococci
Sl. gram-positive cocci in clusters
SUSCEPTIBILITY: S
AMPICILLIN S
CEFAZOLIN S
CEFOTAXIME S
CEFTRIAXONE S
CEFUROXIME S
CEPHALOTHIN S
CIPROFLOXACIN S
ERYTHROMYCIN R
GENTAMICIN S
OXACILLIN S
PENICILLIN S
PIPERACILLIN S
TETRACYCLINE S
TOBRAMYCIN S
TRIMETH/SULF S
VANCOMYCIN S
S= SUSCEPTIBLE
R= RESISTANT,I= INTERMEDIATE,M= MODERATELYSUSCEP
Date: 1/31
History Diagnosis: Pneumonia
Findings: There is slight overexpansion of the lungs.The pulmonary vasculature is normal. The heart is not enlarged.There is lower lobe infiltrate in the right lung.
Impression: Right lower lobepneumonia
EKG
Date: 1/31. Diagnosis:Pneumonia
Interpretation: EKG: NSR, widespread ST-T waveabnormalities, LV hypertrophy
Chemistry
Date: 1/31
Specimen | Results | Normal Values |
GLUC | 281 H | 70-110 |
CREAT | 0.67 | 0.5-1.5 |
NA | 142 | 136-146 |
K | 4.8 | 3.5-5.5 |
CL | 108 | 95-110 |
CO2 | 29 | 24-32 |
CA | 9.5 | 8.4-10.5 |
PHOS | 3.8 | 2.5-4.4 |
MG | 2.8 | 1.6-3.0 |
T BILI | 1.0 | 0.2-1.2 |
D BILI | 0.3 | 0.0-0.5 |
PROTEIN | 6.5 | 6.0-8.0 |
ALBUMIN | 5.1 | 5.0-5.5 |
AST | 38 | 0-40 |
ALT | 54 | 30-65 |
GGT | 50 | 15-85 |
LD | 180 | 100-190 |
ALK PHOS | 102 | 50-136 |
URIC ACID | 4.5 | 2.2-7.7 |
CHOL | 89 | 0-200 |
TRIG | 101 | 10-160 |
Urinalysis
Date: 1/31
Test | Results | Ref Range |
SP GRAVITY | 1.007 | 1.005-1.035 |
PH | 7.0 | 5-7 |
PROT | NEG | NEG |
GLUC | NEG | NEG |
KETONES | NEG | NEG |
BILI | NEG | NEG |
BLOOD | NEG | NEG |
LEU EST | NEG | NEG |
NITRATES | NEG | NEG |
RED SUBS | NEG | NEG |
HEMATOLOGY
DATE: 1/31
Specimen | Results | Normal Values |
WBC | 12.8 H | 4.3-11.0 |
RBC | 5.5 | 4.5-5.9 |
HBG | 13.0 L | 13.5-17.5 |
HCT | 38 L | 41-52 |
MCV | 90 | 80-100 |
MCHC | 41 | 31-57 |
PLT | 251 | 150-450 |
Choose the correct principal diagnosiscode.
E11.65
I10
I12.9
J15.6
K21.9
Choose the correct secondary diagnosiscode(s).
E11.311
E11.319
E10.65
E11.65
I10
I35.0
M17.0
Z16.29
Z79.4
None apply
Choose the correct procedure code(s).
0T9B00Z
0T9B80Z
30233K1
30233R1
30243N0
4A023N7
4A1Z7KZ
4A197LZ
4A1971Z
None apply
Smith and Roberson Business Law
ISBN: 978-0538473637
15th Edition
Authors: Richard A. Mann, Barry S. Roberts