Forum - Questions & Answers

Mar 5th, 2013 - RachaelMayo

ICD 9 Codes

LOCATION: In-patient Hospital
PATIENT: Donald Harris
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.
IMPRESSION:
1. Severe congestive heart failure
2. Hypoxia probably related to the bilateral pleural effusions
3. 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 above scenario:
ICD-9-CM: __________,
ICD-9-CM: __________

Mar 5th, 2013 - agent00711   151 

re: ICD 9 Codes

Rachel, just a friendly reminder, you need to be careful not to post any patient information when copying and pasting.

Mar 5th, 2013 -

re: ICD 9 Codes

Phi!!!!!



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