act like a medical coder provide he princiapal diagnosis FINAL DIAGNOSES: 1. Left anterior chest

act like a medical coder provide he princiapal diagnosis FINAL DIAGNOSES: 1. Left anterior chest pain with cyanosis and tachypnea episodes 2. Probable right lingular pneumonia 3. Alzheimer’s Disease 4. Chronic obstructive pulmonary disease 5. Atrial fibrillation This 80-year-old white male was admitted from the Alzheimer’s unit at St. Ann’s Care Center. He has a history of COPD and presented with increased shortness of breath, tachypnea, and left sided chest pain. Cyanosis was noted by the St. Ann’s staff. He was brought to the ED for evaluation and was diagnosed with possible pneumonitis. He was admitted to Intensive Care to rule out cardiac disease. MEDICATIONS: Remeron 7.5 mg hs ALLERGIES: None. PHYSICAL EXAMINATION: Initial vital signs: T 98.1, P 102 and regular, R 20 and BP 120/69. Unmarkable HEENT exam. No cyanosis noted. Neck supple. No carotid bruits identified. No thyroid enlargement. Chest exam unremarkable except for a rub in the left anterior chest area inferiorly. Cardiovascular exam revealed a normal S1 and S2 with rub present. No heaves or thrills. Regular rhythm was noted. Abdominal examination was unremarkable without organomegaly or masses. Normal bowel sounds. Extremities were negative. No peripheral edema. Excellent peripheral pulses. No ulcerations or areas of skin breakdown were noted. LABS: Initial CBC: hemoglobin 14.5, hematocrit 44.1, MCV mildly decreased at 82.4. WBC: 20,100 with 76 segs 10 bands, 10 lymphs, and 3 monos. Sodium was 141, potassium 4.6, creatinine 1.6, BUN 28 and glucose 153. Alkaline phosphatase was slightly decreased at 50 but otherwise liver functions were normal. Troponin was minimally elevated at 1.2 but CK was normal at 108. Unremarkable UA. EKG showed sinus tachycardia with nonspecific ST-T segment changes. Chest x-ray revealed a prominent epicardial fat pad on the right with a possible infiltrate in the left lingular region. Areas of fibrosis, degenerative disc disease and osteoarthritis changes in the spine were noted. Flat plate and upright x-rays of the abdomen revealed some intra-arterial calcification but no free air or organomegaly. An abdominal ultrasound was done to evaluate the rub and elevated white count. The patient had some possible splenic enlargement but no other noted abnormalities. Patient is status post cholecystectomy INDICATIONS: Abdominal pain. Chest; A single PA view of the chest compared to a 2-12-xx view revealed a prominent epicardial fat pad on the right. On the left a density extends to the left heart border which could represent fibrosis or an unusual epicardial fat pad. Pneumonia would have to be considered with this appearance. Follow up is recommended. Moderately heavy markings are scattered through out the lungs compatible with areas of fibrosis, including the right costophrenic angle. The heart does not appear to be enlarged. The aorta is calcified in the arch area. Moderate to moderately severe degenerative change is noted in the spine. Demineralization compatible with osteoporosis is also suggested. IMPRESSION: Possible pneumonia in the lingula. CHIEF COMPLAINT: Left sided chest pain, shortness of breath HISTORY OF PRESENT ILLNESS: This 80-year-old white male who has been residing at St. Ann’s Care Center. I was called this morning at 6:00. The nurse stated that the patient was coding and short of breath. He was complaining of left-sided chest pain and was cyanotic. The nurse said that she could not get a pulse oximetry. The patient was transferred to the ED via ambulance. I was called again at 6:55 a.m. The patient was breathing normally, was not cyanotic and appeared to be doing well. He acknowledged some abdominal and chest pain. At this time he has no radiation, sweating, or shortness of breath. He denies dysuria, pyuria or hematuria. He states that his bowels move every day and did so yesterday. PAST MEDICAL HISTORY: Alzheimer’s dementia, COPD, history of smoking. MEDICATIONS: Remeron 7.5 mg q hs. ALLERGIES: None. FAMILY HISTORY: Not obtainable. REVIEW OF SYSTEMS: Cardiovascular, pulmonary, and HEENT: See HPI. The remaining systems which could be reviewed were negative. Some systems were unattainable due to the patient’s condition. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.2, pulse 101, respirations 19, blood pressure 120/75. GENERAL: The patient is alert and no acute distress. He has no accessory muscle respiration. He is not presently cynotic. HEENT: Ears: TMs are clear. Eyes: PERRLA. Throat: No erythema. NECK: Supple with no carotid bruits. HEART: Regular rate and rhythm. Small amount of friction rub. ABDOMEN: Soft and nontender, not distended. No abdominal bruits or pulsatile masses. GENITOURINARY: Deferred. RECTAL: Deferred. EXTREMITIES: No peripheral edema. Good peripheral pulses. NEUROMUSCULAR: Able to move all extremities. DIAGNOSTIC STUDIES: Chest x-ray shows chronic changes in the left lung which could merely be a view from a different exposure. Will review the radiology report. Flat and upright abdominal views show no air fluid levels. EKG reports shows nonspecific T-wave changes in the anterior leads. Regular rate and rhythm. Troponin is slightly elevated at 1.1. Amylase is 53. WBC is 20,000 with an MCV of 82.4, MCHC of 26.7, lymphs 11, segs 77 Sodium is 141, potassium 4.6 , chloride 104, glucose 152, BUN 27, creatinine 1.6, ALP low at 49. The rest of the LFTs are normal. CPK is 109. ASSESSMENT: 1. Chest pain, abdominal pain. Rule out myocardial infarction. Elevated WBC of unknown etiology, possible pneumonia. 2. Alzheimer’s dementia 3. Chronic obstructive pulmonary disease PLAN: Admit to rule out MI. Ultrasound to rule out an aneurysm. See protocol orders for chest pain ) Discharged Alive ____ Died ____ Autopsy Yes ____ No ____ ADMISSION SUMMARY SHEET Physician Signature This is a simulated health record created and intended for educational purposes only. All scenarios, names, demographic information, medical events, and data portrayed herein are fictitious. No identification with or similarity to actual persons, living or dead, or to actual events or entities is intended or should be inferred. Any similarity to actual persons or events is purely coincidental. © 2003. American Health Information Management Association Perry, Oliver H. 3733 Valley View Road # 780561 11/01/xx 80 Duxford 605 327-1077 M Widowed S.D. 57100 Antelope ICU #2 215-32-7522 Catholic W Bus Driver (Retired) Non-Hispanic Patricia Olsen Daughter Self 2720 Mountain View, Devils Lake 701 801-7734 2/13/xx 0600 2/14/xx 1045 4/23/xx N/A Dr. William B. Ackerman Dr. Daniel T. Olson 1. Left anterior chest pain with cyanosis and tachypnea episodes 2. Probable right lingular pneumonia 3. Alzheimer’s Disease 4. Chronic obstructive pulmonary disease 5. Atrial fibrillation 1 What is the principal diagnosis? I48.91 J18.1 F02.80 R07.9

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