Oct 28th, 2013 - samcodie84 1
LOCATION: In-patient Hospital
ATTENDING PHYSICIAN: Timothy L. Pleasant, MD
The patient is doing relatively well in general. I believe the sodium of 152 that was done yesterday morning was wrong since it has dropped down to 132 in 6 hours, which is impossible to happen.
He continues to need oxygen and he continues to be hypoxic. His V/Q scan showed intermediate probability, but his ABGs were not suggestive of respiratory alkalosis.
PHYSICAL EXAMINATION: Blood pressure seems to be stable. Heart rate is 70 per minute, paced. He is afebrile. he has decreased air entry bilaterally in the bases. I did not hear any crackles. Abdomen is negative. Extremities show no edema.
Chest x-ray shows some bilateral pleural effusions, more on the right side.
Creatinine was 0.8. Basic metabolic panel was normal today with a sodium of 139.
I. Severe congestive heart failure
II. Hypoxia probably related to the bilateral pleural effusions
III. Pleural effusion
PLAN: Keep the patient in ICU. We will involve physical therapy with him today. I will consult the pulmonologist on call in the morning to check on him and see if we could do a therapeutic and diagnostic thoracentesis, and whether we need to do a pulmonary angiogram to make sure he doesn’t have pulmonary emboli. I believe that most of his hypoxia is related to his severe CHF and his pleural effusions. I discussed this with the patient. he agrees with the plan.
Identify the correct diagnosis (ICD-9-CM) code(s) for the inpatient hospital visit: ICD-9-CM: __________, ICD-9-CM: __________