This 74-year-old male presented to the emergency room last night with complaints of increased weakness and shortness of breath. In the emergency room, he was found to be hypotensive. Blood pressure 83/42 apparently-actually that was the recording at home. In the emergency room, it was 130/80. He was afebrile, tachypneic per usual, respiratory rate of 32, and admitted with acute pneumonia. He was started on Levaquin. He has a history of purulent sputum for several days. Since admission, he feels better; tachypnea and weakness have improved. His blood pressure readings have somewhat improved. His peripheral edema improved with a diuretic.

Prepare a horizontal analysis of the comparative income statement/statement of earnings….
November 8, 2019
Pillow Costs Assignment | Assignment Help Services
November 8, 2019

Please check ICD-9-CM codes to be correct for the operative reports

7.54. History and Physical Exam

Present Illness: This 74-year-old male presented to the emergency room last night with complaints of increased weakness and shortness of breath. In the emergency room, he was found to be hypotensive. Blood pressure 83/42 apparently-actually that was the recording at home. In the emergency room, it was 130/80. He was afebrile, tachypneic per usual, respiratory rate of 32, and admitted with acute pneumonia. He was started on Levaquin. He has a history of purulent sputum for several days. Since admission, he feels better; tachypnea and weakness have improved. His blood pressure readings have somewhat improved. His peripheral edema improved with a diuretic.

Past Medical History: End-stage pulmonary disease, atherosclerotic heart disease and congestive heart failure, gastroesophageal reflux disease, gout, and hypothyroidism

Family History: Unremarkable

Social History: Has six children and is a widower

Physical Exam: On physical examination, blood pressure 102/70, pulse 90, respirations 28. He is pleasant, alert. Color is good. No JVD.

Chest: He has bilateral rales, which are chronic.

Heart: There is a systolic ejection murmur, grade 3, with an S4 gallop.

Abdomen: The abdomen is soft, nontender. No palpable organomegaly.

Extremities: Extremities reveal trace to +1 peripheral edema. He does have some stasis pigmentary changes. He does have clubbing of his fingers.

Musculoskeletal: No atrophic changes

Skin: Unremarkable except as noted

Neurological: He has no focal sensory or motor deficits and reflexes are physiologic.

Impressions: I suspect he probably just has purulent bronchitis and that is the cause of his deterioration. He is on Levaquin and seems to be improving. We will observe until tomorrow. If still doing reasonably well, we will let him go.

Discharge Summary

History of Present Illness: This 74-year-old male with end-stage pulmonary fibrosis was admitted via the emergency room with increased breathlessness. The admitting diagnosis was pneumonia. While here, he did not develop any significant fever.

Laboratory Studies: On admission P02 58, PC02 37, pH 7.45 on 3.5 L, his electrolytes were normal with the exception of BUN 28, creatinine 1.3, white blood cell count 8.6, hemoglobin 11.4, platelet count slightly low 117, urinalysis fairly unremarkable with trace protein, rare red and white blood cells.

Hospital Course: The patient was continued on Levaquin, which had been started 1 day previously. His chest x-ray showed decreased cardiac size from the previous examination, chronic infiltrates bilaterally, no acute infiltrates; pneumonia ruled out. Electrocardiogram showed sinus rhythm, right bundle branch block, left anterior hemiblock. He did receive intravenous diuretic and with this did achieve significant diuresis. My concern at the time of admission was the possible hypotension, which was recorded at home, but all blood pressure recordings here varied from the 100 to 130 systolic range.

Discharge Diagnosis: Probably acute bronchitis with possible mild congestive heart failure.

Are these codes correct? 515, 466.0, 428.0

The post This 74-year-old male presented to the emergency room last night with complaints of increased weakness and shortness of breath. In the emergency room, he was found to be hypotensive. Blood pressure 83/42 apparently-actually that was the recording at home. In the emergency room, it was 130/80. He was afebrile, tachypneic per usual, respiratory rate of 32, and admitted with acute pneumonia. He was started on Levaquin. He has a history of purulent sputum for several days. Since admission, he feels better; tachypnea and weakness have improved. His blood pressure readings have somewhat improved. His peripheral edema improved with a diuretic. appeared first on commompapers.org.

 
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