?lag question: SpacerCode in proper sequence!Discharge Summary11/14/XXDischarge Date:11/17/XXDischarge Diagnosis:The following documentation is from the health record of a 52-year-old patient.Admission Date:Diabetic ketoacidosis, Type 1 diabetesDehydrationCongestive heart failureAortic valve stenosisUrinary tract infection due to?seudomonas aeruginosaHyperkalemiaPeripheral vascular diseaseHypertensionHyperlipidemiaChronic renal insufficiencyOld myocardial infarctionTobacco dependenceCoronary atherosclerosis with native coronariesAdmitting Diagnosis:Diabetic ketoacidosisDiabetes mellitus Type 1DehydrationCongestive heart failureHyperkalemiaHyperlipidemiaHypertensionTobacco dependenceSevere peripheral vascular diseaseAtherosclerotic coronary artery diseaseUrinary tract infectionRenal insufficiencyHistory of CVAPresent Illness:? 52-year-old white female with known diabetes mellitus Type 1, CVAs, cellulitis, hypertension, chronic renal insufficiency, hyperlipidemia, poorly compliant diabetic. Most recently in hospital from September 3 to September 8 with cellulitis, congestive heart failure, poorly controlled diabetes with diabetic ketoacidosis. Discharged home. She was supposed to be following up with her primary care physician doing b.i.d. Accu-Cheks. She was nauseated for the previous two weeks. As soon as she got nauseated, she quit checking her blood sugar level. She cancelled her doctor’s appointment because she was “too sick to go.” She had decreased appetite and was feeling poorly overall. She came to the emergency room with a blood sugar of 737. She had ketones 200 to 250. Her blood urea nitrogen was 75, creatinine 1.8. Her potassium is 6.1, chloride 5, bicarb at 13.Patient is a poor historian, although she is awake and alert at the time of evaluation, on an insulin drip. Overnight her nausea had resolved. The nausea probably occurred because she was in the beginning stages of diabetic ketoacidosis.Hospital Course:?he patient was put on insulin drip. Blood sugars got down. She was put on q.i.d. Accu-Cheks. Once her blood sugar level came down to the 100s, potassium was lowered. I had a very lengthy discussion with patient about the need for keeping doctor’s visits and checking blood sugars. The patient was placed on Cipro. Her electrocardiogram showed a prolonged Q T. The patient went to ultrasound and had sludge and possible small stones in her gallbladder, and it was felt that she was able to be discharged home improved.Discharge Medications/Instructions:?nsulin 70/30, 20 units in the a.m., 20 in the p.m., Rezulin 400 mg q. a.m., Tenormin 50 q.d., Plavix 75 q.d., Monoket 10 mg b.i.d., Lasix 20 mg b.i.d., aspirin 325 q. a.m., Zocor 20 once a day, Oxycotin 20 b.i.d., Prozac 20 q. a.m., Vasotec 5 mg q. a.m., Propulsid 10 mg at Ac and HS, Bactrim DS one tablet every 12 hours. She is to see her primary care physician in one week. She is to call if she has any difficulties.Disposition:?ischarged homeHistory and PhysicalPast Medical History:?he patient has history of renal insufficiency with a blood urea nitrogen of 30 to 40 with a creatinine of 1.2 to 1.4. She has had a CVA, severe peripheral arterial disease. Echocardiogram done shows aortic stenosis, mitral leaflet thickening, normal left ventricular size, normal diabetes. Smokes three to four packs of cigarettes a day. She has hypertension. She has hyperlipidemia. She is dehydrated. She has a history of atherosclerotic coronary artery disease.Medications:?t the time of admission included Rezulin 40 mg q.d., Prozac 20 q.d., Propulsid 10 a.c. and h.s., Vasotec 2.5 two every morning, Atenolol 50 q. a.m., Plavix 75 q. a.m., Lasix 20 milligrams b.i.d., Novolin 70/30 20 units every a.m., aspirin 325 q. a day, vitamin E, iron, Oxycotin 20 a.m. and h.s., Zocor 20 mg at dinner. The patient has no known drug allergies.Lungs:?lear to auscultationHeart:?eveals a regular rate and rhythm without murmurs, gallops, or rubsAbdomen:?oft, nontender, positive bowel sounds, no masses noted social History: She is married but her husband lives out of state and works there. She has one daughter. She does not drink and has smoked about 3 to 4 packs of cigarettes a day since a teenager.Physical Exam:?t the present time, the patient is afebrile, vital signs are stable. She is awake and alert, oriented times 3.HEENT:?upils equal, round, reactive to light and accommodation, extraocular muscles intact, oropharynx benign.Neck:?upple without adenopathy or jugular venous distention.Extremities:?o edema. She has a baseline edema currently. Pulses are absent, pedal pulses.Laboratory:?t the time of admission, her glucose was 737, blood urea nitrogen 75, creatinine 1.8, acetone greater than 200, less than 250, sodium 136, potassium 6.1, chloride 95, bicarb of 13. Her hemoglobin was 13.9 and hematocrit of 44.1, white blood cell count of 9.2 with a left shift showing 80.2 percent neutrophils, 16.2 percent lymphocytes. Platelets were 241,000. Urinalysis shows positive nitrites, greater than 1,000 glucose, 30 protein, 15 ketones, trace hemoglobin. She had 13 white blood count per high power field. Rare red per high power field, 21 bacteria. Gram stain on her u/a showed no organisms seen.Impression(s):Diabetic ketoacidosisDiabetes mellitus Type 1DehydrationCongestive heart failureHyperkalemiaHyperlipidemiaHypertensionTobacco dependenceSevere peripheral vascular disease, arterial in natureAtherosclerotic coronary artery diseaseUrinary tract infectionRenal insufficiencyHistory of CVAPlan:?dmit, hydrate. She has been on insulin drip, we will d/c this now and change to q. 4 Accu-cheks and continue sliding scale. Hopefully on 16th be able to reinstitute her routine meds. Her potassium has now come down to the mid 4’s secondary to her hydration and her sugar being driven intracellular with the insulin drip. I have impressed upon the patient the need for checking blood sugars and keeping M.D. appointment versus death in the future. The patient is on Cipro for her urinary tract infection. Further workup as indicated during hospital stay.Code Assignment Including POA Indicators?lag question: Question 15Question 151?tsCode Assignment Including POA IndicatorsICD-10-CM Principal Diagnosis:?lag question: Question 16Question 160.5?tsICD-10-CM Additional Diagnoses Answer 1:?lag question: Question 17Question 170.5?tsICD-10-CM Additional Diagnoses Answer 2:?lag question: Question 18Question 180.5?tsICD-10-CM Additional Diagnoses Answer 3:?lag question: Question 19Question 190.5?tsICD-10-CM Additional Diagnoses Answer 4:?lag question: Question 20Question 200.5?tsICD-10-CM Additional Diagnoses Answer 5:?lag question: Question 21Question 210.5?tsICD-10-CM Additional Diagnoses Answer 6:?lag question: Question 22Question 220.5?tsICD-10-CM Additional Diagnoses Answer 7:?lag question: Question 23Question 230.5?tsICD-10-CM Additional Diagnoses Answer 8:?lag question: Question 24Question 240.5?tsICD-10-CM Additional Diagnoses Answer 9:?lag question: Question 25Question 250.5?tsICD-10-CM Additional Diagnoses Answer 10:?lag question: Question 26Question 260.5?tsICD-10-CM Additional Diagnoses Answer 11:?lag question: Question 27Question 270.5?tsICD-10-CM Additional Diagnoses Answer 12:?lag question: Question 28Question 280.25?tsICD-10-CM Additional Diagnoses Answer 13:?lag question: Question 29Question 290.25?tsICD-10-CM Additional Diagnoses Answer 14:Health ScienceScienceNursingHIM 210S
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