NU611 2020 September Unit 3 Discussion Latest

NU611 Clinical Decision Making

Unit 3 Discussion

ICD-10 Codes

Instructions:

Review the SOAP note accessed through the link below.

ICD-10 SOAP NotePreview the document

Initial Post

Use your lecture materials to determine what ICD-10 Codes to assign for this patient encounter.

In paragraph form construct a discussion that supports the Codes you identified.

In the discussion explore how the ICD-10 Codes that you assigned impact third party payor reimbursement for this visit.

Please be sure to validate your opinions and ideas with citations and references in APA format where appropriate.

The post and responses are valued at 20 points. Please review post and response expectations. Please review the rubric to ensure that your response meets criteria.

Estimated time to complete: 2 hours

Peer Response: Unit 3, Due Sunday by 11:59 pm CT

ICD-10 Codes

Instructions:

Consider the knowledge you have gained from this week’s lecture.

Construct a response to at least 2 of your peers commenting – ideally one who assigned the same ICD-10 Codes that you did and one who did not.

Please be sure to validate your opinions and ideas with citations and references in APA format where appropriate.

*Subjective:

CC:

HPI: Mrs B is a 64 y/o Caucasian female patient that presents with a cough over the last 4 weeks that is moderate in severity. She initially presented to the walk-in clinic last week and was diagnosed with an upper respiratory infection and was prescribed azithromycin. Mrs. B feels that the antibiotic was not helpful and she has not been sleeping well due to the congestion and cough. She denies nasal discharge but is coughing up clear/white phlem. She reports feeling like she cannot get the mucous out of her chest and feels SOB at times. She denies any body aches, fever, chills, chest pain or poor oral intake.

PMH: PMH includes

Osteopenia (2019), Depressive disorder (1980), hypertension (2016), COPD (2016), hyperlipidemia (2018), type II DM (2018), morbid obesity (2018), Hospitalized (9/2018) for 7 days with pneumonia, Surgery history: Left femur fracture (2018), Hysterectomy- age 45, Appendectomy- age 30, Colonoscopy (2015), Coronary Artery Bypass (CABG) - x5 (2016), Dilation & curettage, Hemorrhoidectomy (2012), Tubal ligation- age 35 Allergies: Keflex- angioedema, Metformin- diarrhea, Quinine- angioedema, Ultramangioedema

Medications:

albuterol sulfate HFA 90 mcg/actuation aerosol inhaler. Inhale 2 puff(s) every 4 hours by

inhalation route.

benzonatate 200 mg po TID PRN

Breo Ellipta 100 mcg-25 mcg/dose powder 1 inhalation every day

Duloxetine 20mg po daily

Finofibrate 160mg po daily

glipiZIDE ER 10 mg tablet po daily

HCTZ 25mg po daily

Rosuvastatin 10mg po daily

Lisinopril 10mg po daily

Metoprolol tartate 25 mg po daily

Social History: Mrs. B is a retired factory worker and has lived in Florida for 3 years. She currently smokes ½ pack of cigarettes for 20 years. Drinks 1-2 beers per week. She is widowed since 2002 husband passed from complications of Emphysema. She has two adult daughters living at home. Her grandchildren live with their father who has sole custody. Mrs. B owns a home which is paid for. Daughter Brenda has two jobs. Her son in law also lives in the home he works. All family members smoke in the house. She has four dogs, 10 outdoor cats, and 5 birds living in the garage.

Family History: Father died of MI age 60

Mother- colon cancer and died at age 70

Health Maintenance/Promotion: Up to date on immunizations, flu (10/2018), pneumonia (1/2018 & 11/18). Colonoscopy and Mammogram up to date (12/2018). Diet- Diabetic. She occasionally exercises by walking.

ROS:

General: Feeling tired, usual weight, and below her baseline of health.

Skin: Denies skin or hair changes

HEENT: Denies headache or injury. Denies vision changes, redness, earaches, or hearing changes. Denies nasal discharge. Sore throat at times from coughing. No muscle aches, itching or sinus trouble.

Respiratory: Productive cough with phlegm that is white/clear. C/o SOB. Last CXR 2019 Cardiovascular: Denies chest pain, dyspnea, orthopnea, or palpitations. Denies rheumatic fever,heart murmur. Pertinent for hypertension. Last BP taken this visit.

*Objective:

PE:

Gen: Well developed female in no apparent distress. She is cooperative and pleasant. Hair is well groomed.

VS: BP 126/78 HR 76 O2 sat 96% on RA RR 20 T 97.9 Height 60 inches Weight 178 LBs BMI

34.8

/Skin: Dry, intact. No rashes or erythema noted.

HEENT: Head without lesions. Hair texture average. Conjunctiva clear without discharge. Ear canals clear, tympanic membrane pearly grey without redness. Hearing grossly intact. Nose without external lesions and mucosa not inflamed. Throat and oral pharynx with mild erythema. Dentures in place, well-fitting without tenderness or abscess noted. No exudate or lesions. No Frontal and maxillary sinus tender to palpation. No lymphadenopathy. Lungs: Chest wall expansion shallow but symmetrical. No use of accessory muscles or SOB noted. Lung sounds with wheezing and rhonchi throughout.

CV: Chest symmetrical. Rate regular. Normal S1 and S2. No carotid bruit. No JVD. No digital clubbing noted. No cyanosis. No murmurs noted. Diagnostic Tests: Chest X-ray- mild chronic bronchitis