:26 A 67 % الله 0 % CASE STUDIES Using the code boot, code and
answer questions about the following case studies. 13-1. CASE STUDY
History and Physical CC: Shortness of breath. HPI: Patient is a
70-year-old female who presents with SOB x1 day. She stat she was
lying down when she felt SOB. SOB was not relieved by standing u
decided to come to the ER because the SOB persisted. She denies
chest p NN or diarrhea. No leg sweling. She has had a cough for the
past couple of da minimal sputum production. No sick contacts. No
sore throat. Her last hemoi session occurred a couple of days ago
Past medical history: ESRD on HD for 6 years. Diabetes mellitus
with la A1C 6.8. Arthritis, chronic hepatitis C, dyslipidemia,
hypertension, sec hyperparathyroidism, and osteoporosis. Patient
had a myocardial infarction years ago. Social history: Patient has
a history of cocaine and heroin use, none now. smokes 3 to 5
cigarettes/day. Allergies include oxycodone and Percocet, both of
which cause itching, Medications: See admission sheet. PHYSICAL
EXAMINATION: VS: T 36.5, HR 84, BP 114/63, RR 24, Sao,, 93% on 3L
of oxygen. General: Lying in bed sleeping. NAD. HEENT: PERRL.
Sclera anicteric. No elevated JVP. Chest: Bibasilar crackles.
Heart: RRR. No murmur. Abd: Soft, nontender, and no guarding.
Extremities: No edema. Neuro: Alert and oriented *3. ASSESSMENT AND
PLAN: Patient is admitted with shortness of breath, which is likely
due to volume o secondary to missing dialysis session and dietary
indiscrimination. Will consul regarding dialysis. No fever, so not
likely an infectious process. DM: Patient on Lantus. Will continue.
HTN: Continue home medications. Discharge Summary
DIAGNOSES/PROBLEMS: 1. End-stage renal disease, on dialysis,
Monday, Wednesday, and Friday; dialysis on Wednesday and came in
short of breath. 2. History of type Il diabetes, but currently not
clear whether she is on therapy 3. Hypertension. Chapter III
O I need the ICD-10-CM diagnosis codes for this case
study
:26 A 67 % الله 0 % CASE STUDIES Using the code boot, code and answer questions about the following case studies. 13-1.
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